1790767895 NPI number — FRED DOELEONG LEE MD

Table of content: FRED DOELEONG LEE MD (NPI 1790767895)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1790767895 NPI number — FRED DOELEONG LEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
FRED
Provider Middle Name:
DOELEONG
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1790767895
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2251 N RAMPART BLVD
Provider Second Line Business Mailing Address:
338
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89128-7640
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
702-733-6263
Provider Business Mailing Address Fax Number:
702-733-1796

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 SHADOW LN
Provider Second Line Business Practice Location Address:
SUITE 207
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89106-4363
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-384-5400
Provider Business Practice Location Address Fax Number:
702-384-0648
Provider Enumeration Date:
11/16/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207V00000X , with the licence number:  NV5204 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 002002733 , issued by the state of ( NV ) . This identifiers is of the category "MEDICAID".




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