Healthcare Provider Details

I. General information

NPI: 1265291520
Provider Name (Legal Business Name): TAEJUN LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4077 FIFTH AVE # MER-35
SAN DIEGO CA
92103-2105
US

IV. Provider business mailing address

4077 FIFTH AVE # MER-35
SAN DIEGO CA
92103-2105
US

V. Phone/Fax

Practice location:
  • Phone: 858-832-2478
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberA209361
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: