=====================================================
General NPI Number Information
=====================================================
NPI Number | 1861631442
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YUNJI LEE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2009
-----------------------------------------------------
Last Update Date | 10/01/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20400 LAKE CHABOT RD STE 304
-----------------------------------------------------
City | CASTRO VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94546-5316
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-537-0700
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 235A PACIFIC AVE
-----------------------------------------------------
City | PIEDMONT
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 94611-3431
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 510-542-1194
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | 723079
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------