Basic Information
| Provider Information | |||||||||
| NPI: | 1174631295 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JONG | ||||||||
| MiddleName: | O. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 815 MARKET ST | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775502725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097706731 | ||||||||
| FaxNumber: | 4097706919 | ||||||||
| Practice Location | |||||||||
| Address1: | 815 MARKET ST | ||||||||
| Address2: | MEDICAL STAFF OFFICE | ||||||||
| City: | GALVESTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 775502725 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4097706731 | ||||||||
| FaxNumber: | 4097706919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/28/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2086S0102X | L8107 | TX | Y | Allopathic & Osteopathic Physicians | Surgery | Surgical Critical Care |
ID Information
| ID | Type | State | Issuer | Description | 8718B7 | 05 | TX | MEDICAID |