Provider Demographics
NPI:1114094703
Name:LEE, JUNG DU (MD)
Entity Type:Individual
Prefix:DR
First Name:JUNG
Middle Name:DU
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JUNG
Other - Middle Name:D
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:262 LINCOLN AVE
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07506-1201
Mailing Address - Country:US
Mailing Address - Phone:973-427-9065
Mailing Address - Fax:973-427-4995
Practice Address - Street 1:220 HAMBURG TPKE STE 4A
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:NJ
Practice Address - Zip Code:07470-2132
Practice Address - Country:US
Practice Address - Phone:973-942-0400
Practice Address - Fax:973-942-0452
Is Sole Proprietor?:No
Enumeration Date:2006-11-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA028375174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJD19227Medicare UPIN
NJ502090BWDMedicare ID - Type Unspecified