Healthcare Provider Details

I. General information

NPI: 1205913969
Provider Name (Legal Business Name): RAY W LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 02/10/2022
Certification Date: 02/10/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

600 MARINE BLVD
MOSS BEACH CA
94038-9641
US

IV. Provider business mailing address

17055 GRANDEE WAY
SAN DIEGO CA
92128-2125
US

V. Phone/Fax

Practice location:
  • Phone: 650-563-7107
  • Fax:
Mailing address:
  • Phone: 703-282-0236
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number0101232526
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberG66832
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: