Provider Demographics
NPI:1205915444
Name:LEE, JONG MIN (DPM)
Entity type:Individual
Prefix:
First Name:JONG
Middle Name:MIN
Last Name:LEE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:10 LIBERTE LN
Mailing Address - Street 2:
Mailing Address - City:CHESTERBROOK
Mailing Address - State:PA
Mailing Address - Zip Code:19087-5721
Mailing Address - Country:US
Mailing Address - Phone:610-584-4143
Mailing Address - Fax:610-584-4143
Practice Address - Street 1:4605 FRANKFORD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19124-5803
Practice Address - Country:US
Practice Address - Phone:215-289-7007
Practice Address - Fax:215-289-3400
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2016-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC005679213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA10009302530001Medicaid
PA5288640001Medicare NSC
076675Medicare PIN
U98672Medicare UPIN