Provider Demographics
NPI:1447359930
Name:LEE-BENNER, LORD A (MD,FACE)
Entity type:Individual
Prefix:
First Name:LORD
Middle Name:A
Last Name:LEE-BENNER
Suffix:
Gender:M
Credentials:MD,FACE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4121 WESTERLY PL STE 204
Mailing Address - Street 2:
Mailing Address - City:NEWPORT BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92660-2338
Mailing Address - Country:US
Mailing Address - Phone:949-903-6021
Mailing Address - Fax:
Practice Address - Street 1:4121 WESTERLY PL STE 204
Practice Address - Street 2:
Practice Address - City:NEWPORT BEACH
Practice Address - State:CA
Practice Address - Zip Code:92660-2338
Practice Address - Country:US
Practice Address - Phone:949-903-6021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG20669207RE0101X, 2084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
Not Answered2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAG20669OtherLICENCE
CAG20669OtherLICENCE