=====================================================
General NPI Number Information
=====================================================
NPI Number | 1023051174
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | BENNETT LEE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/14/2006
-----------------------------------------------------
Last Update Date | 03/07/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2755 ALAMO ST SUITE 101
-----------------------------------------------------
City | SIMI VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93065-1311
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-522-6577
-----------------------------------------------------
Fax | 805-522-7030
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 8510 BALBOA BLVD SUITE 150
-----------------------------------------------------
City | NORTHRIDGE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91325-3583
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-357-5048
-----------------------------------------------------
Fax | 818-654-3417
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | G64625
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------