=====================================================
General NPI Number Information
=====================================================
NPI Number | 1811973472
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | JOHN J LEE MD
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/15/2005
-----------------------------------------------------
Last Update Date | 03/13/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2050 W CHESTER PIKE SUITE 100
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-6701
-----------------------------------------------------
Fax | 610-789-6704
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2050 W CHESTER PIKE SUITE 100
-----------------------------------------------------
City | HAVERTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19083-2742
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-789-6701
-----------------------------------------------------
Fax | 610-789-6704
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207W00000X
-----------------------------------------------------
Taxonomy Name | Ophthalmology Physician
-----------------------------------------------------
License Number | MD071940L
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------