Healthcare Provider Details

I. General information

NPI: 1922366780
Provider Name (Legal Business Name): BRENT MICHAEL LEM MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/30/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 N STATE ST CLINIC TOWER A7D
LOS ANGELES CA
90033-5000
US

IV. Provider business mailing address

1100 N STATE ST CLINIC TOWER A7D
LOS ANGELES CA
90033-5000
US

V. Phone/Fax

Practice location:
  • Phone: 323-409-6931
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberA119419
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: