Provider Demographics
NPI:1811942857
Name:LEE, YOON JAE (MD)
Entity type:Individual
Prefix:DR
First Name:YOON JAE
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:YOON
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1924
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-0034
Mailing Address - Country:US
Mailing Address - Phone:678-473-1445
Mailing Address - Fax:
Practice Address - Street 1:3400 MCCLURE BRIDGE RD
Practice Address - Street 2:A102
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-6675
Practice Address - Country:US
Practice Address - Phone:678-473-1445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-24
Last Update Date:2014-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA051971207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA10BDHLBMedicare PIN
I25166Medicare UPIN