Provider Demographics
NPI:1568466431
Name:LEE, EDWARD M (MD)
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:M
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:MIN
Other - Middle Name:LAE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 W CENTER STREET PROMENADE STE 300
Mailing Address - Street 2:
Mailing Address - City:ANAHEIM
Mailing Address - State:CA
Mailing Address - Zip Code:92805-3960
Mailing Address - Country:US
Mailing Address - Phone:714-449-4841
Mailing Address - Fax:714-937-6233
Practice Address - Street 1:100 E. VALENCIA MESA DRIVE
Practice Address - Street 2:SUITE 206
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92835
Practice Address - Country:US
Practice Address - Phone:714-446-5050
Practice Address - Fax:714-446-5116
Is Sole Proprietor?:No
Enumeration Date:2005-06-09
Last Update Date:2018-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77837207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
G77837Medicare ID - Type Unspecified
CADJ191ZMedicare PIN
G05817Medicare UPIN