Provider Demographics
NPI:1710307962
Name:LEE, JONATHAN ALAN (MD)
Entity Type:Individual
Prefix:
First Name:JONATHAN
Middle Name:ALAN
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 1:4515 SETON CENTER PKWY
Mailing Address - Street 2:SUITE 215-CREDENTIALING
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78759-5290
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:512-406-6216
Practice Address - Street 1:3828 S 1ST ST
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-7048
Practice Address - Country:US
Practice Address - Phone:512-443-1311
Practice Address - Fax:512-406-6266
Is Sole Proprietor?:No
Enumeration Date:2014-04-25
Last Update Date:2016-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXA128889207Q00000X
TXQ5853207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX356166401Medicaid
TX356166402Medicaid
TX356166401Medicaid
485559YKXYMedicare PIN