Provider Demographics
NPI:1902894694
Name:LEE, JAE KYU (MD)
Entity Type:Individual
Prefix:
First Name:JAE
Middle Name:KYU
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 1:1320 COACHMAN CT
Mailing Address - Street 2:
Mailing Address - City:ASHLAND
Mailing Address - State:OH
Mailing Address - Zip Code:44805-4443
Mailing Address - Country:US
Mailing Address - Phone:419-289-1151
Mailing Address - Fax:419-281-8767
Practice Address - Street 1:1320 COACHMAN CT
Practice Address - Street 2:
Practice Address - City:ASHLAND
Practice Address - State:OH
Practice Address - Zip Code:44805-4443
Practice Address - Country:US
Practice Address - Phone:419-289-1151
Practice Address - Fax:419-281-8767
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-10-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35037115174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0441258Medicaid
OH0441258Medicaid
OHE30106Medicare UPIN