Healthcare Provider Details

I. General information

NPI: 1497810378
Provider Name (Legal Business Name): JASON M LEE-LLACER MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/22/2006
Last Update Date: 06/09/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2001 MEDICAL PKWY ACUTE CARE PAVILION
ANNAPOLIS MD
21401-3280
US

IV. Provider business mailing address

PO BOX 64916
BALTIMORE MD
21264-4916
US

V. Phone/Fax

Practice location:
  • Phone: 443-481-1000
  • Fax:
Mailing address:
  • Phone: 443-481-6467
  • Fax: 443-481-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberD0064818
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: