MEDICARE: DR. JAEDU 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	2084P0800X	Psychiatry Physician	363LP0808X	NY

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	:	1952349144
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JAEDU LEE M.D.

Provider Business Mailing Address
First Line	:	60 TIMBERPOINT DR
Second Line	:
City	:	NORTHPORT
State	:	NY
Zip	:	11768-2227
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1727 N OCEAN AVE
Second Line	:
City	:	MEDFORD
State	:	NY
Zip	:	11763-2649
Country	:	US
Telephone Number	:	631-654-1919
Fax Number	:

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

Provider Enumeration Date	:	06/02/2006
Last Update Date	:	07/08/2007

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