Provider Demographics
NPI:1316046154
Name:LEE, JEON W (MD)
Entity Type:Individual
Prefix:
First Name:JEON
Middle Name:W
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 1:4602 DEPARTMENT
Mailing Address - Street 2:
Mailing Address - City:CAROL STREAM
Mailing Address - State:IL
Mailing Address - Zip Code:60122-0021
Mailing Address - Country:US
Mailing Address - Phone:906-225-4821
Mailing Address - Fax:906-225-4537
Practice Address - Street 1:1414 W FAIR AVE
Practice Address - Street 2:SUITE 211
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-2675
Practice Address - Country:US
Practice Address - Phone:906-225-3912
Practice Address - Fax:906-225-7538
Is Sole Proprietor?:No
Enumeration Date:2006-09-21
Last Update Date:2009-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI070506207RP1001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4334943Medicaid
MI290014109OtherRAILROAD MEDICARE
F50419Medicare UPIN
MI4334943Medicaid