Provider Demographics
NPI:1336599869
Name:LEE, JOHN JONGHYUN (DO)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:JONGHYUN
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:JONG
Other - Middle Name:HYUN
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:3200 W KIMBERLY RD STE 208
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52806-3059
Mailing Address - Country:US
Mailing Address - Phone:563-421-0280
Mailing Address - Fax:563-421-0289
Practice Address - Street 1:1345 W CENTRAL PARK AVE
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52804
Practice Address - Country:US
Practice Address - Phone:563-421-4409
Practice Address - Fax:563-421-4449
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2021-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IADO-05051207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine