Provider Demographics
NPI:1740555291
Name:DAVID CHANG LEE MD LTD
Entity type:Organization
Organization Name:DAVID CHANG LEE MD LTD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:CHANG
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:708-687-6440
Mailing Address - Street 1:5320 W 159TH ST
Mailing Address - Street 2:SUITE 302
Mailing Address - City:OAK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60452-3333
Mailing Address - Country:US
Mailing Address - Phone:708-687-6440
Mailing Address - Fax:708-687-9311
Practice Address - Street 1:5320 159TH ST
Practice Address - Street 2:SUITE 302
Practice Address - City:OAK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60452-4705
Practice Address - Country:US
Practice Address - Phone:708-687-6440
Practice Address - Fax:708-687-9311
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-03-16
Last Update Date:2012-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36048308174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========6045201Medicaid
IL=========6045201Medicaid
ILC40257Medicare UPIN