Provider Demographics
NPI:1871892133
Name:LEE, SAMUEL (MD)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3170 LOMA VISTA RD
Mailing Address - Street 2:
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93003-2970
Mailing Address - Country:US
Mailing Address - Phone:805-648-9830
Mailing Address - Fax:
Practice Address - Street 1:3170 LOMA VISTA RD
Practice Address - Street 2:
Practice Address - City:VENTURA
Practice Address - State:CA
Practice Address - Zip Code:93003-2970
Practice Address - Country:US
Practice Address - Phone:805-648-9830
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-24
Last Update Date:2015-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA123222208100000X, 208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & Rehabilitation