Healthcare Provider Details

I. General information

NPI: 1710967435
Provider Name (Legal Business Name): TAE AHN THOMAS LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 01/19/2006
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

658 W MARKET ST SUITE 200
LIMA OH
45801-4563
US

IV. Provider business mailing address

658 W MARKET ST SUITE 200
LIMA OH
45801-4563
US

V. Phone/Fax

Practice location:
  • Phone: 419-227-5176
  • Fax:
Mailing address:
  • Phone: 419-227-5176
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number35100036
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA33710
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number35100036
License Number StateOH
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License NumberA33710
License Number StateCA

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: