Basic Information
| Provider Information | |||||||||
| NPI: | 1770088619 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ANDREW | ||||||||
| MiddleName: | YEON | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 841 PRUDENTIAL DR STE 1130 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046334199 | ||||||||
| FaxNumber: | 9046334188 | ||||||||
| Practice Location | |||||||||
| Address1: | 841 PRUDENTIAL DR STE 1130 | ||||||||
| Address2: | |||||||||
| City: | JACKSONVILLE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 322078331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9046334199 | ||||||||
| FaxNumber: | 9046334188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2018 | ||||||||
| LastUpdateDate: | 08/24/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | UO6029 | FL | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 208000000X | OS17478 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
No ID Information.