Healthcare Provider Details

I. General information

NPI: 1366596132
Provider Name (Legal Business Name): JEONG RAN OH LEE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/22/2007
Last Update Date: 01/10/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14 HEYWARD ST
BROOKLYN NY
11249-7823
US

IV. Provider business mailing address

14 HEYWARD ST
BROOKLYN NY
11249-7823
US

V. Phone/Fax

Practice location:
  • Phone: 718-260-4600
  • Fax: 718-852-0867
Mailing address:
  • Phone: 718-260-4600
  • Fax: 718-852-0867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number196624
License Number StateNY

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: