Provider Demographics
NPI:1831353291
Name:DR. JOHN LEE MD PC
Entity type:Organization
Organization Name:DR. JOHN LEE MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:W
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:319-524-6311
Mailing Address - Street 1:484 MESSENGER RD
Mailing Address - Street 2:
Mailing Address - City:KEOKUK
Mailing Address - State:IA
Mailing Address - Zip Code:52632-2115
Mailing Address - Country:US
Mailing Address - Phone:319-524-6311
Mailing Address - Fax:319-524-0868
Practice Address - Street 1:484 MESSENGER RD
Practice Address - Street 2:
Practice Address - City:KEOKUK
Practice Address - State:IA
Practice Address - Zip Code:52632-2115
Practice Address - Country:US
Practice Address - Phone:319-524-6311
Practice Address - Fax:319-524-0868
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-15
Last Update Date:2014-11-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA20680207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0138560Medicaid
IA0138560Medicaid
IAE46639Medicare UPIN