MEDICARE: DR. GRACE SON LEE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2085R0202X	Diagnostic Radiology Physician	A101258	CA

General Provider Information

NPI Number	:	1174703854
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. GRACE SON LEE MD

Provider Business Mailing Address
First Line	:	751 S BASCOM AVE
Second Line	:	DIAGNOSTIC IMAGING DEPT
City	:	SAN JOSE
State	:	CA
Zip	:	95128-2604
Country	:	US
Telephone Number	:	408-885-5000
Fax Number	:

Provider Business Practice Location Address
First Line	:	2810 LONG BEACH BLVD FL 2
Second Line	:
City	:	LONG BEACH
State	:	CA
Zip	:	90806-1558
Country	:	US
Telephone Number	:	562-933-7833
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/09/2007
Last Update Date	:	09/21/2023

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