Provider Demographics
NPI:1205806155
Name:LEE, JOHN MARTIN JR (MD)
Entity type:Individual
Prefix:
First Name:JOHN
Middle Name:MARTIN
Last Name:LEE
Suffix:JR
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 1:1542 MEDICAL PARK CIR
Mailing Address - Street 2:
Mailing Address - City:TUPELO
Mailing Address - State:MS
Mailing Address - Zip Code:38801-6560
Mailing Address - Country:US
Mailing Address - Phone:662-844-4711
Mailing Address - Fax:662-844-9619
Practice Address - Street 1:1542 MEDICAL PARK CIR
Practice Address - Street 2:
Practice Address - City:TUPELO
Practice Address - State:MS
Practice Address - Zip Code:38801-6560
Practice Address - Country:US
Practice Address - Phone:662-844-4711
Practice Address - Fax:662-844-9619
Is Sole Proprietor?:No
Enumeration Date:2006-01-24
Last Update Date:2008-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS10710207RN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00010520Medicaid
MS0114538OtherBLUE CROSS BLUE SHIELD MS
MS10710OtherSTATE LIC NUMBER
AL009002820Medicaid
73012088OtherBLUE CROSS BLUE SHIELD/ OTHER STATES
640600391OtherTAX ID NUMBER
640600391OtherTAX ID NUMBER
MS00010520Medicaid
MSE33340Medicare UPIN
MS0114538OtherBLUE CROSS BLUE SHIELD MS