Provider Demographics
NPI:1538146907
Name:LEE, VIVIEN H (MD)
Entity type:Individual
Prefix:
First Name:VIVIEN
Middle Name:H
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:VIVIEN
Other - Middle Name:HYOUN HAE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:700 ACKERMAN RD STE 2120
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43202-1559
Mailing Address - Country:US
Mailing Address - Phone:614-293-4969
Mailing Address - Fax:614-366-7004
Practice Address - Street 1:920 N HAMILTON RD
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-1757
Practice Address - Country:US
Practice Address - Phone:614-293-4969
Practice Address - Fax:614-293-6111
Is Sole Proprietor?:No
Enumeration Date:2005-12-28
Last Update Date:2021-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH351282162084N0400X
IL0361168212084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0172863Medicaid
IL036-116821Medicaid
ILK31240Medicare UPIN
OH0172863Medicaid