MEDICARE: JACK LEE M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1083675318
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACK LEE M.D.

Provider Business Mailing Address
First Line	:	245 UNION AVE
Second Line	:	2C
City	:	BRIDGEWATER
State	:	NJ
Zip	:	08807-3064
Country	:	US
Telephone Number	:	908-722-5115
Fax Number	:	908-722-9515

Provider Business Practice Location Address
First Line	:	245 UNION AVE
Second Line	:	2C
City	:	BRIDGEWATER
State	:	NJ
Zip	:	08807-3064
Country	:	US
Telephone Number	:	908-722-5115
Fax Number	:	908-722-9515

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/28/2006
Last Update Date	:	02/06/2015

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