Healthcare Provider Details

I. General information

NPI: 1851975882
Provider Name (Legal Business Name): PAUL TAEGYU LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/06/2021
Last Update Date: 07/05/2024
Certification Date: 06/27/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 PROSPECT AVE
HACKENSACK NJ
07601-1915
US

IV. Provider business mailing address

220 EAST COLUMBIA AVE UNIT A
PALISADES PARK NJ
07650-4900
US

V. Phone/Fax

Practice location:
  • Phone: 551-996-2000
  • Fax:
Mailing address:
  • Phone: 201-638-0767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberMT223285
License Number StatePA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: