Provider Demographics
NPI:1205836699
Name:LEE, JUAN C (MD)
Entity Type:Individual
Prefix:
First Name:JUAN
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2700 UNIVERSITY SQUARE DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33612-5513
Mailing Address - Country:US
Mailing Address - Phone:813-253-2721
Mailing Address - Fax:813-253-2299
Practice Address - Street 1:2700 UNIVERSITY SQUARE DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-5513
Practice Address - Country:US
Practice Address - Phone:813-253-2721
Practice Address - Fax:813-253-2299
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-28
Last Update Date:2017-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA049913174400000X
FLME1015782085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA00909466BMedicaid
FL003288400Medicaid
GA30BDJXRMedicare ID - Type UnspecifiedMEDICARE
GA00909466BMedicaid