Provider Demographics
NPI:1851618995
Name:LEE, JASON DOLE (MD)
Entity Type:Individual
Prefix:DR
First Name:JASON
Middle Name:DOLE
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 1:660 S EUCLID AVE
Mailing Address - Street 2:CB 8224
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:618-236-1000
Mailing Address - Fax:618-236-9847
Practice Address - Street 1:1418 CROSS ST
Practice Address - Street 2:STE 160
Practice Address - City:SHILOH
Practice Address - State:IL
Practice Address - Zip Code:62269-2988
Practice Address - Country:US
Practice Address - Phone:618-607-1320
Practice Address - Fax:618-433-6492
Is Sole Proprietor?:No
Enumeration Date:2010-04-29
Last Update Date:2021-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0361378852085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO200057311Medicaid