MEDICARE: JAE HOON 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	207QG0300X	Geriatric Medicine (Family Medicine) Physician	A109172	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	A109172	OTHER	CA	LICENSE
2	LL1795	OTHER	NV	NV MEDICAL LIC

General Provider Information

NPI Number	:	1912105297
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JAE HOON LEE M.D.

Provider Business Mailing Address
First Line	:	5016 CHESEBRO RD
Second Line	:	STE 200
City	:	AGOURA HILLS
State	:	CA
Zip	:	91301-2210
Country	:	US
Telephone Number	:	818-528-6164
Fax Number	:	818-991-1200

Provider Business Practice Location Address
First Line	:	520 N MAIN ST STE 120
Second Line	:
City	:	SANTA ANA
State	:	CA
Zip	:	92701-4623
Country	:	US
Telephone Number	:	714-352-5800
Fax Number	:	714-352-5801

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

Provider Enumeration Date	:	07/06/2007
Last Update Date	:	08/19/2019

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Directions to “ JAE HOON LEE M.D.” Practice Location

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