Healthcare Provider Details

I. General information

NPI: 1407885981
Provider Name (Legal Business Name): JOHN K LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/30/2006
Last Update Date: 10/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2845 GREENBRIER RD
GREEN BAY WI
54311-6519
US

IV. Provider business mailing address

164 N BROADWAY
GREEN BAY WI
54303-2728
US

V. Phone/Fax

Practice location:
  • Phone: 920-288-4930
  • Fax: 920-288-4941
Mailing address:
  • Phone: 920-965-4055
  • Fax: 920-405-5388

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085N0904X
TaxonomyNuclear Radiology Physician
License Number35836
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: