MEDICARE: DR. CHANG SUP LEE MD

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	A172874	CA
2	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1598296238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. CHANG SUP LEE MD

Provider Business Mailing Address
First Line	:	520 S VIRGIL AVE STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1425
Country	:	US
Telephone Number	:	404-783-3508
Fax Number	:	213-297-7978

Provider Business Practice Location Address
First Line	:	520 S VIRGIL AVE STE 103
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90020-1425
Country	:	US
Telephone Number	:	404-783-3508
Fax Number	:	213-297-7978

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

Provider Enumeration Date	:	03/24/2017
Last Update Date	:	02/26/2026

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Directions to “ DR. CHANG SUP LEE MD” Practice Location

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