Provider Demographics
NPI:1124100367
Name:LEE, GORDON ELIOT (MD)
Entity type:Individual
Prefix:MR
First Name:GORDON
Middle Name:ELIOT
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 1:1505 SOQUEL DRIVE
Mailing Address - Street 2:SUITE 8
Mailing Address - City:SANTA CRUZ
Mailing Address - State:CA
Mailing Address - Zip Code:95065-1716
Mailing Address - Country:US
Mailing Address - Phone:831-476-4230
Mailing Address - Fax:831-476-0571
Practice Address - Street 1:1505 SOQUEL DRIVE
Practice Address - Street 2:SUITE 8
Practice Address - City:SANTA CRUZ
Practice Address - State:CA
Practice Address - Zip Code:95065-1716
Practice Address - Country:US
Practice Address - Phone:831-476-4230
Practice Address - Fax:831-476-0571
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-19
Last Update Date:2012-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG29794207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA4087118Medicaid
CA00G297940Medicare ID - Type Unspecified
A44166Medicare UPIN