Provider Demographics
NPI:1609984814
Name:LEE, JAE YOON (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:YOON
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 1:518 VALLEYVIEW PL
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10314-5535
Mailing Address - Country:US
Mailing Address - Phone:718-983-9777
Mailing Address - Fax:
Practice Address - Street 1:13124 ROCKAWAY BLVD
Practice Address - Street 2:
Practice Address - City:SOUTH OZONE PARK
Practice Address - State:NY
Practice Address - Zip Code:11420-2932
Practice Address - Country:US
Practice Address - Phone:718-659-7166
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-28
Last Update Date:2013-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY164410207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00995955Medicaid
A64657Medicare UPIN
NY89D02Medicare ID - Type Unspecified