Provider Demographics
NPI:1952693228
Name:LEE, MICHAEL JERRY (MD)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:JERRY
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 1:125 WALKER STREET FLOOR 2
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10013
Mailing Address - Country:US
Mailing Address - Phone:212-226-8866
Mailing Address - Fax:212-226-2289
Practice Address - Street 1:136-26 37TH AVENUE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-1721
Practice Address - Country:US
Practice Address - Phone:718-886-1222
Practice Address - Fax:718-886-7576
Is Sole Proprietor?:No
Enumeration Date:2011-05-05
Last Update Date:2019-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY272737208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03797564Medicaid