=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831983758
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MATTHEW JON LEE
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/07/2025
-----------------------------------------------------
Last Update Date | 04/07/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 350 ENGLE ST
-----------------------------------------------------
City | ENGLEWOOD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07631-1808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-894-3143
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 REINER PL
-----------------------------------------------------
City | ENGLEWOOD CLIFFS
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07632-2033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-390-9028
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------