Healthcare Provider Details

I. General information

NPI: 1548314313
Provider Name (Legal Business Name): THOMAS KEYWON LEE MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 02/10/2020
Certification Date: 02/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 HOAG DR
NEWPORT BEACH CA
92663-4162
US

IV. Provider business mailing address

2901 W COAST HWY STE 200
NEWPORT BEACH CA
92663-4045
US

V. Phone/Fax

Practice location:
  • Phone: 949-764-4624
  • Fax: 949-764-5435
Mailing address:
  • Phone: 949-891-1297
  • Fax: 949-625-8010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberA106146
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZP0101X
TaxonomyAnatomic Pathology Physician
License NumberT1602
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: