Provider Demographics
NPI:1104909357
Name:LEE, CHAN WOO (MD)
Entity type:Individual
Prefix:
First Name:CHAN
Middle Name:WOO
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1201 24TH ST
Mailing Address - Street 2:B-200
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93301-2310
Mailing Address - Country:US
Mailing Address - Phone:661-324-4431
Mailing Address - Fax:
Practice Address - Street 1:1201 24TH ST
Practice Address - Street 2:B-200
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93301-2310
Practice Address - Country:US
Practice Address - Phone:661-324-4431
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-23
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA89666208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAI 24681Medicare UPIN
CA00A896661Medicare PIN