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General NPI Number Information
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NPI Number | 1942769831
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Entity Type | Individual
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Provider Name | IVAN JISOO LEE MD
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Gender | Male
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Dates
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Enumeration Date | 03/19/2019
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Last Update Date | 12/02/2025
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Provider Practice Location Address
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Address Line | 301 W BASTANCHURY RD STE 285
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City | FULLERTON
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State | CA
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Zip | 92835-3432
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Country | US
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Telephone | 714-738-4620
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Fax |
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Provider Business Mailing Address
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Address Line | 301 W BASTANCHURY RD STE 285
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City | FULLERTON
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State | CA
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Zip | 92835-3432
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Country | US
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Telephone | 714-738-4620
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | A200827
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License Number State | CA
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Taxonomy #2
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Taxonomy Code | 207W00000X
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Taxonomy Name | Ophthalmology Physician
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License Number | 35.147835
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License Number State | OH
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