Provider Demographics
NPI:1043227291
Name:LEE, JOHN B (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:B
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:
Other - Last Name:BYUNG LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1351 W ALTGELD ST APT 4A
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60614-2969
Mailing Address - Country:US
Mailing Address - Phone:773-327-4781
Mailing Address - Fax:773-465-4769
Practice Address - Street 1:1506 W HOWARD ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60626-1708
Practice Address - Country:US
Practice Address - Phone:773-465-0695
Practice Address - Fax:773-465-4769
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2011-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208000000X208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036063002Medicaid
IL31600265OtherBC/BS
IL036063002Medicaid
IL31600265OtherBC/BS