1023004413 NPI number — JUSTIN T LEE MD

Table of content: JUSTIN T LEE MD (NPI 1023004413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1023004413 NPI number — JUSTIN T LEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
JUSTIN
Provider Middle Name:
T
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1023004413
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/17/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5001 S COOPER ST STE 201
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARLINGTON
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76017-5993
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
866-367-8768
Provider Business Mailing Address Fax Number:
817-541-9555

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5005 S COOPER ST STE 250
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ARLINGTON
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76017-5996
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
866-367-8768
Provider Business Practice Location Address Fax Number:
817-541-9540
Provider Enumeration Date:
09/21/2005

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 208800000X , with the licence number:  L3726 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 150756804 . This is a "MEDICAID OTHER" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
  • Identifier: 150756801 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 150756802 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 150756803 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
  • Identifier: 150756805 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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