Provider Demographics
NPI:1083675318
Name:LEE, JACK (MD)
Entity type:Individual
Prefix:
First Name:JACK
Middle Name:
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 1:245 UNION AVE
Mailing Address - Street 2:2C
Mailing Address - City:BRIDGEWATER
Mailing Address - State:NJ
Mailing Address - Zip Code:08807-3064
Mailing Address - Country:US
Mailing Address - Phone:908-722-5115
Mailing Address - Fax:908-722-9515
Practice Address - Street 1:245 UNION AVE
Practice Address - Street 2:2C
Practice Address - City:BRIDGEWATER
Practice Address - State:NJ
Practice Address - Zip Code:08807-3064
Practice Address - Country:US
Practice Address - Phone:908-722-5115
Practice Address - Fax:908-722-9515
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2015-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0058947Medicaid
NJ0058947Medicaid
NJ0058947Medicaid