MEDICARE: DR. SALVACION MIRAFUENTES 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	208D00000X	General Practice Physician	A45616	CA

General Provider Information

NPI Number	:	1700920147
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SALVACION MIRAFUENTES LEE M.D.

Provider Business Mailing Address
First Line	:	11306 VENTURA BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-3137
Country	:	US
Telephone Number	:	818-505-1574
Fax Number	:	818-505-1574

Provider Business Practice Location Address
First Line	:	11306 VENTURA BLVD
Second Line	:
City	:	STUDIO CITY
State	:	CA
Zip	:	91604-3137
Country	:	US
Telephone Number	:	818-505-1574
Fax Number	:	818-505-1574

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

Provider Enumeration Date	:	02/19/2007
Last Update Date	:	07/08/2007

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