Healthcare Provider Details

I. General information

NPI: 1396737763
Provider Name (Legal Business Name): LEE LEAK JR. MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/22/2005
Last Update Date: 05/21/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 NEW BRUNSWICK AVE
PERTH AMBOY NJ
08861-3674
US

IV. Provider business mailing address

66 WEST GILBERT STREET
RED BANK NJ
07701-4918
US

V. Phone/Fax

Practice location:
  • Phone: 732-442-3700
  • Fax:
Mailing address:
  • Phone: 732-212-0060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License Number'25MA07798300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: