Provider Demographics
NPI:1477569978
Name:LEASE, JOHN G (MD)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:G
Last Name:LEASE
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 1:3000 NORTH HALSTED STREET
Mailing Address - Street 2:SUITE 707
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60657
Mailing Address - Country:US
Mailing Address - Phone:773-883-8234
Mailing Address - Fax:773-404-9718
Practice Address - Street 1:3000 NORTH HALSTED STREET
Practice Address - Street 2:SUITE 707
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60657
Practice Address - Country:US
Practice Address - Phone:773-883-8234
Practice Address - Fax:773-404-9718
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-01
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
518390Medicare ID - Type Unspecified
E18661Medicare UPIN