Healthcare Provider Details

I. General information

NPI: 1831515865
Provider Name (Legal Business Name): CHI-CHAN LEE M.D
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2014
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date: 10/21/2014
Reactivation Date: 11/25/2014

III. Provider practice location address

1210 SONOMA AVE
SANTA ROSA CA
95405-6648
US

IV. Provider business mailing address

1210 SONOMA AVE
SANTA ROSA CA
95405-6648
US

V. Phone/Fax

Practice location:
  • Phone: 707-523-7185
  • Fax:
Mailing address:
  • Phone: 707-523-7185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberC208622
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code202D00000X
TaxonomyIntegrative Medicine Physician
License NumberC208622
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207RC0200X
TaxonomyCritical Care Medicine (Internal Medicine) Physician
License NumberC208622
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: