Healthcare Provider Details

I. General information

NPI: 1386740124
Provider Name (Legal Business Name): JOHN J W LEE MD PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/16/2006
Last Update Date: 03/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1360 WYOMING AVE
SCRANTON PA
18509
US

IV. Provider business mailing address

2050 WEST CHESTER PIKE SUITE 100
HAVERTOWN PA
19083
US

V. Phone/Fax

Practice location:
  • Phone: 570-504-5888
  • Fax: 610-566-6107
Mailing address:
  • Phone: 610-789-6701
  • Fax: 610-789-6704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD071940L
License Number StatePA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierDD3906
Identifier TypeOTHER
Identifier StatePA
Identifier IssuerRAILROAD MEDICARE

VIII. Authorized Official

Name: JOHN J W LEE
Title or Position: PRESIDENT
Credential: MD
Phone: 610-789-6701