Provider Demographics
NPI:1124282645
Name:LEE, LARISSE K (MD)
Entity type:Individual
Prefix:
First Name:LARISSE
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4955 VAN NUYS BLVD
Mailing Address - Street 2:SUITE 704
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91403
Mailing Address - Country:US
Mailing Address - Phone:818-325-0400
Mailing Address - Fax:818-325-0404
Practice Address - Street 1:4955 VAN NUYS BLVD
Practice Address - Street 2:SUITE 704
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91403
Practice Address - Country:US
Practice Address - Phone:818-325-0400
Practice Address - Fax:818-325-0404
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-14
Last Update Date:2019-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2398302086S0129X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0129XAllopathic & Osteopathic PhysiciansSurgeryVascular Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA117214OtherMEDICAL BOARD STATE LICENSE