=====================================================
General NPI Number Information
=====================================================
NPI Number | 1689561763
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | SIAK LEE MBBS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/20/2025
-----------------------------------------------------
Last Update Date | 06/20/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 747 52ND ST
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94609-1809
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-428-3410
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2640 SHATTUCK AVE APT 213
-----------------------------------------------------
City | BERKELEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94704-3261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 415-340-9316
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207LP3000X
-----------------------------------------------------
Taxonomy Name | Pediatric Anesthesiology Physician
-----------------------------------------------------
License Number | SPI889
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------