Healthcare Provider Details

I. General information

NPI: 1740630995
Provider Name (Legal Business Name): JOHN LEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2016
Last Update Date: 04/27/2026
Certification Date: 04/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

593 EDDY STREET DEPARTMENT OF RADIOLOGY
PROVIDENCE RI
02903
US

IV. Provider business mailing address

593 EDDY ST DEPT OF
PROVIDENCE RI
02903-4923
US

V. Phone/Fax

Practice location:
  • Phone: 919-610-9448
  • Fax:
Mailing address:
  • Phone: 919-610-9448
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0204X
TaxonomyVascular & Interventional Radiology Physician
License NumberMD17642
License Number StateRI
# 2
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License NumberMD17642
License Number StateRI
# 3
Primary TaxonomyN
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number270807
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: