Provider Demographics
NPI:1144267444
Name:LEE, OH JEONG (MD)
Entity type:Individual
Prefix:
First Name:OH
Middle Name:JEONG
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 1:513 RIDGE RD STE 3
Mailing Address - Street 2:
Mailing Address - City:MUNSTER
Mailing Address - State:IN
Mailing Address - Zip Code:46321-1648
Mailing Address - Country:US
Mailing Address - Phone:219-513-6388
Mailing Address - Fax:219-513-6389
Practice Address - Street 1:513 RIDGE RD STE 3
Practice Address - Street 2:
Practice Address - City:MUNSTER
Practice Address - State:IN
Practice Address - Zip Code:46321-1648
Practice Address - Country:US
Practice Address - Phone:219-513-6388
Practice Address - Fax:219-513-6389
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-02
Last Update Date:2025-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036069355207R00000X
IN01035185A207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100014510AMedicaid
IL036069355T2Medicaid
IL036069355T2Medicaid
IN183620Medicare ID - Type Unspecified