Provider Demographics
NPI:1972967065
Name:LEE, SUSAN (DO, MPH)
Entity type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DO, MPH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1212 W 17TH ST
Mailing Address - Street 2:
Mailing Address - City:SANTA ANA
Mailing Address - State:CA
Mailing Address - Zip Code:92706-3418
Mailing Address - Country:US
Mailing Address - Phone:714-954-0432
Mailing Address - Fax:
Practice Address - Street 1:1212 W 17TH ST
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92706-3418
Practice Address - Country:US
Practice Address - Phone:714-954-0432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-04-05
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A16917207Q00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program