Provider Demographics
NPI:1437154960
Name:LEE, BRYANT B (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYANT
Middle Name:B
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 1:150 FLORAL AVE
Mailing Address - Street 2:
Mailing Address - City:NEW PROVIDENCE
Mailing Address - State:NJ
Mailing Address - Zip Code:07974-1557
Mailing Address - Country:US
Mailing Address - Phone:908-273-4300
Mailing Address - Fax:
Practice Address - Street 1:75E NORTHFIELD RD
Practice Address - Street 2:
Practice Address - City:LIVINGSTON
Practice Address - State:NJ
Practice Address - Zip Code:07039-4532
Practice Address - Country:US
Practice Address - Phone:973-436-1400
Practice Address - Fax:908-673-7336
Is Sole Proprietor?:No
Enumeration Date:2005-06-21
Last Update Date:2015-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA07925300174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ02428077Medicaid
NJ094361CP0Medicare PIN
NJ02428077Medicaid