Provider Demographics
NPI:1639112055
Name:LEE, JASON HESUNG (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:HESUNG
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 1:39700 BOB HOPE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:RANCHO MIRAGE
Mailing Address - State:CA
Mailing Address - Zip Code:92270-3267
Mailing Address - Country:US
Mailing Address - Phone:760-341-2360
Mailing Address - Fax:760-346-5940
Practice Address - Street 1:39700 BOB HOPE DR
Practice Address - Street 2:SUITE 202
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-3267
Practice Address - Country:US
Practice Address - Phone:760-341-2360
Practice Address - Fax:760-346-5940
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2021-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD425992208VP0014X
NJ25MA08008400208VP0014X
CAA1081132081P2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain Medicine
No208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ1014610230002Medicaid
PA101461023001Medicaid
NJ1699298OtherAETNA
NJ54-2177172OtherPROCURA
NJ54-2177172OtherTRICARE (GROUP)
CAA108113OtherCA LICENSE
PAX003305501OtherAMERICHOICE
NJ54-2177172OtherCHN (GROUP)
NJ54-2177172OtherHORIZON BLUE CROSS BLUE SHIELD
NJ6694216OtherCIGNA
NJ0091511Medicaid
CA330808867OtherBLUE CROSS
NJ221971OtherUS FAMILY HEALTH PLAN
PA2692016000OtherKEYSTONE MEDICARE 65
CAP00756965OtherMC RAIL ROAD
CAP00756965OtherMC RAIL ROAD
NJ54-2177172OtherPROCURA
145075Medicare UPIN
NJ098251V6LMedicare PIN
NJ098251TU3Medicare PIN