Healthcare Provider Details

I. General information

NPI: 1699479923
Provider Name (Legal Business Name): JAE SUNG LEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/30/2026
Certification Date: 07/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15408 NORTHERN BLVD STE 2I
FLUSHING NY
11354-5042
US

IV. Provider business mailing address

15408 NORTHERN BLVD STE 2I
FLUSHING NY
11354-5042
US

V. Phone/Fax

Practice location:
  • Phone: 718-358-3151
  • Fax:
Mailing address:
  • Phone: 718-358-3151
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number343264
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: