Provider Demographics
NPI:1306144514
Name:LEE, MARK (DO)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:MARK
Other - Middle Name:D
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:DO
Mailing Address - Street 1:PO BOX 829641
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19182-9641
Mailing Address - Country:US
Mailing Address - Phone:267-370-5296
Mailing Address - Fax:215-230-3725
Practice Address - Street 1:4897 YORK ROAD
Practice Address - Street 2:
Practice Address - City:BUCKINGHAM
Practice Address - State:PA
Practice Address - Zip Code:18912-0278
Practice Address - Country:US
Practice Address - Phone:215-794-7471
Practice Address - Fax:215-794-2576
Is Sole Proprietor?:No
Enumeration Date:2011-03-11
Last Update Date:2019-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MB09360100207QA0505X
PAOS015870207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
367403JZWMedicare Oscar/Certification