Healthcare Provider Details

I. General information

NPI: 1568091460
Provider Name (Legal Business Name): EDWARD JIN LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2020
Last Update Date: 09/23/2025
Certification Date: 09/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

630 W 168TH ST
NEW YORK NY
10032-3725
US

IV. Provider business mailing address

4444 W PINE BLVD APT 111
SAINT LOUIS MO
63108-2347
US

V. Phone/Fax

Practice location:
  • Phone: 551-795-6727
  • Fax:
Mailing address:
  • Phone: 551-795-6727
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084V0102X
TaxonomyVascular Neurology Physician
License Number329352
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: