=====================================================
General NPI Number Information
=====================================================
NPI Number | 1730673328
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JIA WEN LEE DO
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/18/2018
-----------------------------------------------------
Last Update Date | 07/27/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2850 HOG MOUNTAIN RD STE 101
-----------------------------------------------------
City | DACULA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30019-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-614-7170
-----------------------------------------------------
Fax | 770-614-8233
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2850 HOG MOUNTAIN RD STE 101
-----------------------------------------------------
City | DACULA
-----------------------------------------------------
State | GA
-----------------------------------------------------
Zip | 30019-5935
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 770-614-7170
-----------------------------------------------------
Fax | 770-614-8233
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | LL52029
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 207R00000X
-----------------------------------------------------
Taxonomy Name | Internal Medicine Physician
-----------------------------------------------------
License Number | 89138
-----------------------------------------------------
License Number State | GA
-----------------------------------------------------