Provider Demographics
NPI:1467532929
Name:LEE, JOHN W (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
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 1:10 CARRIAGE GREEN EST
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-2100
Mailing Address - Country:US
Mailing Address - Phone:319-524-6311
Mailing Address - Fax:319-524-0868
Practice Address - Street 1:484 MESSENGER RD
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-2115
Practice Address - Country:US
Practice Address - Phone:319-524-6311
Practice Address - Fax:319-524-0868
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0138560Medicaid
IA13856Medicare PIN
IAE46639Medicare UPIN