Provider Demographics
NPI:1063444271
Name:LEE, JONG Y (MD)
Entity type:Individual
Prefix:DR
First Name:JONG
Middle Name:Y
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 1:1611 NW 12TH AVE
Mailing Address - Street 2:BOX 016960 (M851)
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33136-1005
Mailing Address - Country:US
Mailing Address - Phone:305-243-6358
Mailing Address - Fax:305-243-8470
Practice Address - Street 1:1611 NW 12TH AVE
Practice Address - Street 2:BOX 016960 (M851)
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33136-1005
Practice Address - Country:US
Practice Address - Phone:305-243-6358
Practice Address - Fax:305-243-8470
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2009-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME89153207L00000X
PAMD436059207L00000X, 207LC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No207LC0200XAllopathic & Osteopathic PhysiciansAnesthesiologyCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2698528-00Medicaid
PA43304OtherMEDICARE ID/UNSPECIFIED
FL2698528-00Medicaid
FL43304Medicare ID - Type Unspecified
PA2698528-00Medicaid
FL2698528-00Medicaid