MEDICARE: DR. BONNIE J LEE M.D.

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	207RG0300X	Geriatric Medicine (Internal Medicine) Physician	1711891205	UT

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1790779106
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. BONNIE J LEE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 2106
Second Line	:
City	:	SANDY
State	:	UT
Zip	:	84091-2106
Country	:	US
Telephone Number	:	801-557-4595
Fax Number	:	801-596-8080

Provider Business Practice Location Address
First Line	:	554 S 800 E
Second Line	:
City	:	SLC
State	:	UT
Zip	:	84102-2931
Country	:	US
Telephone Number	:	801-557-4595
Fax Number	:	801-596-8080

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

Provider Enumeration Date	:	08/31/2005
Last Update Date	:	02/11/2009

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