Provider Demographics
NPI:1205245628
Name:LEE, RICHARD JOE (DO)
Entity type:Individual
Prefix:DR
First Name:RICHARD
Middle Name:JOE
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 E 33RD ST FL 5
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10016-5337
Mailing Address - Country:US
Mailing Address - Phone:212-366-4459
Mailing Address - Fax:347-823-1561
Practice Address - Street 1:89-111 PORTER AVENUE
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11237
Practice Address - Country:US
Practice Address - Phone:347-294-2435
Practice Address - Fax:347-294-2439
Is Sole Proprietor?:Yes
Enumeration Date:2014-08-11
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY287169207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training ProgramGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY4846571Medicaid