Provider Demographics
NPI:1194889105
Name:JEROME LEE SANG MD, PA
Entity type:Organization
Organization Name:JEROME LEE SANG MD, PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JEROME
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE SANG
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:361-643-6623
Mailing Address - Street 1:107 CEDAR DR
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:TX
Mailing Address - Zip Code:78374
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:107 CEDAR DR
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:TX
Practice Address - Zip Code:78374
Practice Address - Country:US
Practice Address - Phone:361-643-6623
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-21
Last Update Date:2010-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX147440501Medicaid
00924ROtherBCBS
=========OtherTAX ID NUMBER
TX00924RMedicare PIN