MEDICARE: ON-TAT LEE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207W00000X	Ophthalmology Physician	A138659	CA

General Provider Information

NPI Number	:	1194084517
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ON-TAT LEE M.D.

Provider Business Mailing Address
First Line	:	1617 SAINT MARKS PLZ STE D
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6478
Country	:	US
Telephone Number	:	209-478-1797
Fax Number	:	209-478-1224

Provider Business Practice Location Address
First Line	:	1617 SAINT MARKS PLZ STE D
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95207-6478
Country	:	US
Telephone Number	:	209-478-1797
Fax Number	:	209-478-1224

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/04/2012
Last Update Date	:	07/14/2023

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