Healthcare Provider Details

I. General information

NPI: 1821029794
Provider Name (Legal Business Name): NINA LEE-TALL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2006
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 S PACIFIC COAST HWY STE C
REDONDO BEACH CA
90277-4987
US

IV. Provider business mailing address

1200 S PACIFIC COAST HWY STE C
REDONDO BEACH CA
90277-4987
US

V. Phone/Fax

Practice location:
  • Phone: 310-375-2102
  • Fax: 310-791-6319
Mailing address:
  • Phone: 310-375-2102
  • Fax: 310-791-6319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207YX0007X
TaxonomyPlastic Surgery within the Head & Neck (Otolaryngology) Physician
License NumberA61349
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: