MEDICARE: KELLY JIEUN LEE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program
2	2084P0800X	Psychiatry Physician	U8550	TX

General Provider Information

NPI Number	:	1124647086
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KELLY JIEUN LEE MD

Provider Business Mailing Address
First Line	:	7703 FLOYD CURL DR # MC7792
Second Line	:
City	:	SAN ANTONIO
State	:	TX
Zip	:	78229-3901
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	328 CRYSTAL CITY HWY
Second Line	:
City	:	UVALDE
State	:	TX
Zip	:	78801-6124
Country	:	US
Telephone Number	:	800-662-6052
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/10/2020
Last Update Date	:	08/15/2024

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