Basic Information
| Provider Information | |||||||||
| NPI: | 1639667553 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | DEREK | ||||||||
| MiddleName: | JUSTIN | ||||||||
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| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 90 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | MIDDLETOWN | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064573649 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 25 NEW HAMPSHIRE AVE STE 100 | ||||||||
| Address2: | |||||||||
| City: | PORTSMOUTH | ||||||||
| State: | NH | ||||||||
| PostalCode: | 038012845 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6034312516 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2018 | ||||||||
| LastUpdateDate: | 08/31/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/31/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 207Q00000X | 22654 | NH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.