Healthcare Provider Details

I. General information

NPI: 1164124491
Provider Name (Legal Business Name): JAE EUN LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 07/16/2026
Certification Date: 07/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 N STATE ST STE 3300
LOS ANGELES CA
90089-1001
US

IV. Provider business mailing address

1200 N STATE ST STE 3300
LOS ANGELES CA
90089-1001
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-7422
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207T00000X
TaxonomyNeurological Surgery Physician
License NumberA202106
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: