Provider Demographics
NPI:1932110319
Name:LEE, SHIN JAE (MD)
Entity Type:Individual
Prefix:DR
First Name:SHIN
Middle Name:JAE
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 1:30 E JUNIPER LN
Mailing Address - Street 2:
Mailing Address - City:MORELAND HILLS
Mailing Address - State:OH
Mailing Address - Zip Code:44022-1376
Mailing Address - Country:US
Mailing Address - Phone:440-247-9520
Mailing Address - Fax:
Practice Address - Street 1:1400 TOD AVE NW
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:OH
Practice Address - Zip Code:44485-2483
Practice Address - Country:US
Practice Address - Phone:330-392-0311
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-10
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35039468L2084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHC03214Medicare UPIN