Provider Demographics
NPI:1013108422
Name:LEE, OTTO K (MD)
Entity type:Individual
Prefix:
First Name:OTTO
Middle Name:K
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 1:7020 W 79TH ST
Mailing Address - Street 2:
Mailing Address - City:BRIDGEVIEW
Mailing Address - State:IL
Mailing Address - Zip Code:60455-4030
Mailing Address - Country:US
Mailing Address - Phone:708-599-8200
Mailing Address - Fax:708-599-8306
Practice Address - Street 1:7020 W 79TH ST
Practice Address - Street 2:
Practice Address - City:BRIDGEVIEW
Practice Address - State:IL
Practice Address - Zip Code:60455-4030
Practice Address - Country:US
Practice Address - Phone:708-599-8200
Practice Address - Fax:708-599-8306
Is Sole Proprietor?:No
Enumeration Date:2007-08-09
Last Update Date:2011-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036117514207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL0222075OtherBLUE CROSS GROUP NUMBER
IL363149833OtherTAX IDENTIFICATION NUMBER
IL3631498336019001OtherCDPG HFS PAYEE ID
IL482450OtherMEDICARE GROUP NUMBER
IL036117514Medicaid
ILP00425248OtherMEDICARE RAILROAD
ILK10310Medicare PIN