Provider Demographics
NPI:1265499917
Name:LEE, JOHN (DO)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:
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 1:2422 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTABULA
Mailing Address - State:OH
Mailing Address - Zip Code:44004-4985
Mailing Address - Country:US
Mailing Address - Phone:440-992-4422
Mailing Address - Fax:440-994-7678
Practice Address - Street 1:2422 LAKE AVE
Practice Address - Street 2:
Practice Address - City:ASHTABULA
Practice Address - State:OH
Practice Address - Zip Code:44004-4985
Practice Address - Country:US
Practice Address - Phone:440-992-4422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2017-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34007251207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2137628Medicaid
OH2137628Medicaid
OHLE7293141Medicare ID - Type UnspecifiedMEDICARE