Healthcare Provider Details

I. General information

NPI: 1760463400
Provider Name (Legal Business Name): JASON O LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2005
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

836 FARMINGTON AVENUE SUITE 207
WEST HARTFORD CT
06119
US

IV. Provider business mailing address

836 FARMINGTON AVENUE SUITE 207
WEST HARTFORD CT
06119
US

V. Phone/Fax

Practice location:
  • Phone: 860-232-9911
  • Fax: 860-233-5996
Mailing address:
  • Phone: 860-232-9911
  • Fax: 860-233-5996

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207KI0005X
TaxonomyClinical & Laboratory Immunology (Allergy & Immunology) Physician
License Number038654
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number038654
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: