Provider Demographics
NPI:1043665433
Name:LEE, DIANA (MD)
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:
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 1:2271 W MALVERN AVE # 85
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2106
Mailing Address - Country:US
Mailing Address - Phone:657-286-5375
Mailing Address - Fax:
Practice Address - Street 1:2226 N STATE COLLEGE BLVD
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92831-1361
Practice Address - Country:US
Practice Address - Phone:657-286-5375
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-04
Last Update Date:2023-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD473433207W00000X
390200000X
CAA151310207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program