Provider Demographics
NPI:1710075239
Name:LEE, PAUL JAW-SHYANG (DO)
Entity Type:Individual
Prefix:
First Name:PAUL
Middle Name:JAW-SHYANG
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:PAUL
Other - Middle Name:J
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 99335
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76199-0335
Mailing Address - Country:US
Mailing Address - Phone:817-920-6300
Mailing Address - Fax:
Practice Address - Street 1:855 MONTGOMERY
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76107-2553
Practice Address - Country:US
Practice Address - Phone:817-920-6300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-10
Last Update Date:2015-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL4521207P00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0027NKOtherBCBS
TX156295111Medicaid
TX139342101OtherFIRSTCARE INDIVIDUAL #
TX156295110Medicaid
TX8BQ000OtherBCBS
TX156295117Medicaid
TX8EX921OtherBCBS
TXH78243Medicare UPIN
TX156295117Medicaid
TX8K7529Medicare PIN