Provider Demographics
NPI:1013072990
Name:LEE, JOHN C (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:C
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 1:1714 S BLAINE LN
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:IL
Mailing Address - Zip Code:62521-5025
Mailing Address - Country:US
Mailing Address - Phone:217-423-9000
Mailing Address - Fax:217-423-9002
Practice Address - Street 1:1714 S BLAINE LN
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:IL
Practice Address - Zip Code:62521-5025
Practice Address - Country:US
Practice Address - Phone:217-423-9000
Practice Address - Fax:217-423-9002
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL001491OtherHEALTH ALLIANCE
IL0554210001OtherDMEPOS
IL0554210001OtherDMEPOS
IL237480Medicare ID - Type Unspecified