MEDICARE: GAVIN LEE

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	390200000X	Student in an Organized Health Care Education/Training Program
2	213ES0103X	Foot & Ankle Surgery Podiatrist	E5623	CA

General Provider Information

NPI Number	:	1760978290
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GAVIN LEE

Provider Business Mailing Address
First Line	:	4773 HAZELNUT AVE
Second Line	:
City	:	SEAL BEACH
State	:	CA
Zip	:	90740-3016
Country	:	US
Telephone Number	:	562-296-3015
Fax Number	:

Provider Business Practice Location Address
First Line	:	7210 N MILBURN AVE STE 101
Second Line	:
City	:	FRESNO
State	:	CA
Zip	:	93722-8449
Country	:	US
Telephone Number	:	559-224-5101
Fax Number	:

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

Provider Enumeration Date	:	07/09/2018
Last Update Date	:	08/12/2020

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Directions to “ GAVIN LEE ” Practice Location

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