Provider Demographics
NPI:1083906747
Name:LEE, JESSICA (MD)
Entity Type:Individual
Prefix:
First Name:JESSICA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 MOTOR PKWY STE A2
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-5112
Mailing Address - Country:US
Mailing Address - Phone:631-234-5666
Mailing Address - Fax:631-234-0539
Practice Address - Street 1:200 MOTOR PKWY STE A2
Practice Address - Street 2:
Practice Address - City:HAUPPAUGE
Practice Address - State:NY
Practice Address - Zip Code:11788-5112
Practice Address - Country:US
Practice Address - Phone:631-234-5666
Practice Address - Fax:631-234-0539
Is Sole Proprietor?:No
Enumeration Date:2011-05-12
Last Update Date:2021-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY274142207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04003590Medicaid