Healthcare Provider Details

I. General information

NPI: 1407485782
Provider Name (Legal Business Name): JONATHAN C LEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/19/2026
Certification Date: 08/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1455 BROAD ST STE 250
BLOOMFIELD NJ
07003-3066
US

IV. Provider business mailing address

1455 BROAD ST STE 250
BLOOMFIELD NJ
07003-3066
US

V. Phone/Fax

Practice location:
  • Phone: 877-532-7837
  • Fax:
Mailing address:
  • Phone: 877-532-7837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081P2900X
TaxonomyPain Medicine (Physical Medicine & Rehabilitation) Physician
License Number25MB12511600
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: