MEDICARE: DR. SANG DAE LEE DPM

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	213ES0103X	Foot & Ankle Surgery Podiatrist	E4416	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
3	P00147789	OTHER	CA	RAILROAD

General Provider Information

NPI Number	:	1780694356
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. SANG DAE LEE DPM

Provider Business Mailing Address
First Line	:	467 REDTAIL DR
Second Line	:
City	:	BREA
State	:	CA
Zip	:	92823-1040
Country	:	US
Telephone Number	:	909-882-3800
Fax Number	:

Provider Business Practice Location Address
First Line	:	2095 N WATERMAN AVE
Second Line	:
City	:	SAN BERNARDINO
State	:	CA
Zip	:	92404-4834
Country	:	US
Telephone Number	:	909-882-3800
Fax Number	:	909-882-3380

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

Provider Enumeration Date	:	08/08/2006
Last Update Date	:	09/11/2009

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Directions to “ DR. SANG DAE LEE DPM” Practice Location

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