Healthcare Provider Details

I. General information

NPI: 1134102858
Provider Name (Legal Business Name): ADA LEE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/28/2005
Last Update Date: 05/09/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE WFAN BUILDING 3RD FLOOR
HACKENSACK NJ
07601-1914
US

IV. Provider business mailing address

30 PROSPECT AVE WFAN BUILDING 3RD FLOOR
HACKENSACK NJ
07601-1914
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-5207
  • Fax: 551-996-4969
Mailing address:
  • Phone: 551-996-5207
  • Fax: 551-996-4969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number218995
License Number StateNY
# 2
Primary TaxonomyY
Taxonomy Code2080P0214X
TaxonomyPediatric Pulmonology Physician
License Number25MA08071400
License Number StateNJ

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier02598965
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: