Provider Demographics
NPI:1992975957
Name:LEE, SUSAN JUNG (MD)
Entity type:Individual
Prefix:
First Name:SUSAN
Middle Name:JUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:27231 LA PAZ RD STE A
Mailing Address - Street 2:
Mailing Address - City:LAGUNA NIGUEL
Mailing Address - State:CA
Mailing Address - Zip Code:92677-3627
Mailing Address - Country:US
Mailing Address - Phone:949-643-9111
Mailing Address - Fax:949-643-8916
Practice Address - Street 1:27231 LA PAZ RD STE A
Practice Address - Street 2:
Practice Address - City:LAGUNA NIGUEL
Practice Address - State:CA
Practice Address - Zip Code:92677-3627
Practice Address - Country:US
Practice Address - Phone:949-643-9111
Practice Address - Fax:949-643-8916
Is Sole Proprietor?:No
Enumeration Date:2008-03-06
Last Update Date:2021-11-05
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAA102538207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CACE563XMedicare PIN