1891778056 NPI number — JOSEPH G LEE MD

Table of content: JOSEPH G LEE MD (NPI 1891778056)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1891778056 NPI number — JOSEPH G LEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
JOSEPH
Provider Middle Name:
G
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:
1891778056
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/13/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
650 S TOWN CENTER DR
Provider Second Line Business Mailing Address:
APT 1087
Provider Business Mailing Address City Name:
LAS VEGAS
Provider Business Mailing Address State Name:
NV
Provider Business Mailing Address Postal Code:
89144-4419
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
541-980-9796
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8689 W CHARLESTON BLVD
Provider Second Line Business Practice Location Address:
STE 105
Provider Business Practice Location Address City Name:
LAS VEGAS
Provider Business Practice Location Address State Name:
NV
Provider Business Practice Location Address Postal Code:
89117-5519
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
702-304-5900
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/22/2005

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: 207R00000X , with the licence number:  14802 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 287210 , issued by the state of ( OR ) . This identifiers is of the category "MEDICAID".




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