Provider Demographics
NPI:1104034107
Name:LEE, NELLIE (MD)
Entity Type:Individual
Prefix:
First Name:NELLIE
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 1:190 EUCLID AVE
Mailing Address - Street 2:
Mailing Address - City:RIDGEFIELD PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07660-1742
Mailing Address - Country:US
Mailing Address - Phone:201-440-3366
Mailing Address - Fax:
Practice Address - Street 1:190 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:RIDGEFIELD PARK
Practice Address - State:NJ
Practice Address - Zip Code:07660-1742
Practice Address - Country:US
Practice Address - Phone:201-440-3366
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA02733100207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ2998301Medicaid
NJD18581Medicare UPIN
NJ2998301Medicaid