Provider Demographics
NPI:1619024486
Name:LEE, JOON NAM (MD)
Entity Type:Individual
Prefix:
First Name:JOON
Middle Name:NAM
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:8279 WEBB RD
Mailing Address - Street 2:
Mailing Address - City:RIVERDALE
Mailing Address - State:GA
Mailing Address - Zip Code:30274-4176
Mailing Address - Country:US
Mailing Address - Phone:770-471-7706
Mailing Address - Fax:770-968-0727
Practice Address - Street 1:696 MOUNT ZION RD
Practice Address - Street 2:SUITE C-4
Practice Address - City:JONESBORO
Practice Address - State:GA
Practice Address - Zip Code:30236-1597
Practice Address - Country:US
Practice Address - Phone:770-968-1746
Practice Address - Fax:770-968-0727
Is Sole Proprietor?:No
Enumeration Date:2007-01-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA015017207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000135572IMedicaid
GAD40423Medicare UPIN
GA000135572IMedicaid