Provider Demographics
NPI:1639667553
Name:LEE, DEREK JUSTIN (DO)
Entity Type:Individual
Prefix:
First Name:DEREK
Middle Name:JUSTIN
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 NEW HAMPSHIRE AVE STE 100
Mailing Address - Street 2:
Mailing Address - City:PORTSMOUTH
Mailing Address - State:NH
Mailing Address - Zip Code:03801-2845
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:25 NEW HAMPSHIRE AVE STE 100
Practice Address - Street 2:
Practice Address - City:PORTSMOUTH
Practice Address - State:NH
Practice Address - Zip Code:03801-2845
Practice Address - Country:US
Practice Address - Phone:603-431-2516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-26
Last Update Date:2023-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH22654207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine