Healthcare Provider Details

I. General information

NPI: 1114447315
Provider Name (Legal Business Name): JASON J LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2017
Last Update Date: 03/28/2023
Certification Date: 03/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

330 ORCHARD ST
NEW HAVEN CT
06511-4417
US

IV. Provider business mailing address

330 ORCHARD ST
NEW HAVEN CT
06511-4417
US

V. Phone/Fax

Practice location:
  • Phone: 203-785-2815
  • Fax: 203-737-8035
Mailing address:
  • Phone: 203-785-2815
  • Fax: 203-737-8035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number272095
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number73501
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: