Provider Demographics
NPI:1811950454
Name:LEE, JOHNNY (MD)
Entity type:Individual
Prefix:DR
First Name:JOHNNY
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 VANDERBILT DR
Mailing Address - Street 2:
Mailing Address - City:LAKE SUCCESS
Mailing Address - State:NY
Mailing Address - Zip Code:11020-1117
Mailing Address - Country:US
Mailing Address - Phone:212-532-0888
Mailing Address - Fax:
Practice Address - Street 1:35 E 35TH ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10016-3823
Practice Address - Country:US
Practice Address - Phone:212-532-0888
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-06
Last Update Date:2018-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY203375207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01905926Medicaid
NYG96223Medicare UPIN
NY01905926Medicaid