=====================================================
General NPI Number Information
=====================================================
NPI Number | 1457593238
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | FRED THOMAS JUNFEI LEE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/25/2009
-----------------------------------------------------
Last Update Date | 05/04/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4275 BURNHAM AVE STE 230
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89119
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-686-0707
-----------------------------------------------------
Fax | 702-733-6899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2251 N RAMPART BLVD # 338
-----------------------------------------------------
City | LAS VEGAS
-----------------------------------------------------
State | NV
-----------------------------------------------------
Zip | 89128-7640
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-686-0707
-----------------------------------------------------
Fax | 702-733-6899
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208600000X
-----------------------------------------------------
Taxonomy Name | Surgery Physician
-----------------------------------------------------
License Number | 47951
-----------------------------------------------------
License Number State | KY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 208200000X
-----------------------------------------------------
Taxonomy Name | Plastic Surgery Physician
-----------------------------------------------------
License Number | 17930
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------