Provider Demographics
NPI:1558641464
Name:LEE, JIWON (MD)
Entity type:Individual
Prefix:
First Name:JIWON
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:PO BOX 7232-DEPT 165
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46207-7232
Mailing Address - Country:US
Mailing Address - Phone:317-614-9850
Mailing Address - Fax:800-731-0751
Practice Address - Street 1:2001 W 86TH ST
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46260-1902
Practice Address - Country:US
Practice Address - Phone:317-614-9850
Practice Address - Fax:317-614-9655
Is Sole Proprietor?:No
Enumeration Date:2011-08-23
Last Update Date:2015-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01073766A207L00000X
PAMT 200476208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice