Provider Demographics
NPI:1588792915
Name:LEE, LAURE MARIEBRADFORD (MD)
Entity type:Individual
Prefix:DR
First Name:LAURE
Middle Name:MARIEBRADFORD
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 1:417 MACE BLVD STE J
Mailing Address - Street 2:#242
Mailing Address - City:DAVIS
Mailing Address - State:CA
Mailing Address - Zip Code:95618-6077
Mailing Address - Country:US
Mailing Address - Phone:707-427-4025
Mailing Address - Fax:
Practice Address - Street 1:1800 HARRISON ST
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94612-3466
Practice Address - Country:US
Practice Address - Phone:707-427-4025
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2021-12-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG84542207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG17376Medicare UPIN