Provider Demographics
NPI:1285632950
Name:LEE, THOMAS Y (MD)
Entity Type:Individual
Prefix:
First Name:THOMAS
Middle Name:Y
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 1:4510 CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:MOUNT LAUREL
Mailing Address - State:NJ
Mailing Address - Zip Code:08054-2210
Mailing Address - Country:US
Mailing Address - Phone:856-439-0060
Mailing Address - Fax:856-452-0344
Practice Address - Street 1:4510 CHURCH RD
Practice Address - Street 2:
Practice Address - City:MOUNT LAUREL
Practice Address - State:NJ
Practice Address - Zip Code:08054-2210
Practice Address - Country:US
Practice Address - Phone:856-439-0060
Practice Address - Fax:856-452-0344
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-07
Last Update Date:2020-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07756900207Q00000X, 207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJI18311Medicare UPIN
NJ084110S9TMedicare ID - Type Unspecified