=====================================================
General NPI Number Information
=====================================================
NPI Number | 1376811406
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LARISSE LEE MD PC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/04/2011
-----------------------------------------------------
Last Update Date | 12/03/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4955 VAN NUYS BLVD SUITE 704
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-325-0400
-----------------------------------------------------
Fax | 818-325-0404
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4955 VAN NUYS BLVD SUITE 704
-----------------------------------------------------
City | SHERMAN OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91403
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 818-325-0400
-----------------------------------------------------
Fax | 818-325-0404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MD & PRESIDENT
-----------------------------------------------------
Name | DR. LARISSE KATHERINE LEE
-----------------------------------------------------
Credential | M.D.
-----------------------------------------------------
Telephone | 818-325-0400
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2086S0129X
-----------------------------------------------------
Taxonomy Name | Vascular Surgery Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------