Provider Demographics
NPI:1538653217
Name:LEE, JACK (MD)
Entity Type:Individual
Prefix:
First Name:JACK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11 FRIENDS LN STE 115
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN
Mailing Address - State:PA
Mailing Address - Zip Code:18940-1885
Mailing Address - Country:US
Mailing Address - Phone:609-799-1600
Mailing Address - Fax:267-358-5166
Practice Address - Street 1:11 FRIENDS LN STE 115
Practice Address - Street 2:
Practice Address - City:NEWTOWN
Practice Address - State:PA
Practice Address - Zip Code:18940-1885
Practice Address - Country:US
Practice Address - Phone:609-799-1600
Practice Address - Fax:267-358-5166
Is Sole Proprietor?:No
Enumeration Date:2018-06-18
Last Update Date:2024-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA11878200207N00000X, 207ND0101X
PAMD482446207N00000X, 207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology