Provider Demographics
NPI:1760463400
Name:LEE, JASON O (MD)
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:O
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:836 FARMINGTON AVENUE
Mailing Address - Street 2:SUITE 207
Mailing Address - City:WEST HARTFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06119
Mailing Address - Country:US
Mailing Address - Phone:860-232-9911
Mailing Address - Fax:860-233-5996
Practice Address - Street 1:836 FARMINGTON AVENUE
Practice Address - Street 2:SUITE 207
Practice Address - City:WEST HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06119
Practice Address - Country:US
Practice Address - Phone:860-232-9911
Practice Address - Fax:860-233-5996
Is Sole Proprietor?:No
Enumeration Date:2005-11-09
Last Update Date:2022-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT038654207KI0005X, 207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
No207KI0005XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyClinical & Laboratory Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
043518OtherAETNA
CT001386540Medicaid
CT00138654000Medicaid
1179424002OtherCIGNA
004394508OtherMEDICAID GROUP CAAC
224829OtherPREFERRED ONE
038654OtherCONNECTICARE
CTOV7942Medicaid
P2666151OtherOXFORD
010038654CT01OtherBLUE CROSS
004394508OtherMEDICAID GROUP CAAC
010038654CT01OtherBLUE CROSS