Provider Demographics
NPI:1902034812
Name:LEE, ERNEST J (MD)
Entity Type:Individual
Prefix:DR
First Name:ERNEST
Middle Name:J
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 1:1 GREYSTONE CIR
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5610
Mailing Address - Country:US
Mailing Address - Phone:201-835-4460
Mailing Address - Fax:
Practice Address - Street 1:1 GREYSTONE CIR
Practice Address - Street 2:
Practice Address - City:MIDDLETON
Practice Address - State:WI
Practice Address - Zip Code:53562-5610
Practice Address - Country:US
Practice Address - Phone:201-835-4460
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2024-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI67949-20208M00000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1902034812Medicaid
CAGC140ZMedicare PIN