Basic Information
| Provider Information | |||||||||
| NPI: | 1851378665 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | L. | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D., PH.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 720 HARRISON AVE | ||||||||
| Address2: | DOB 503 | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 02118 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 732 HARRISON AVENUE | ||||||||
| Address2: | PRESTON FAMILY BUILDING, 2ND FLOOR | ||||||||
| City: | BOSTON | ||||||||
| State: | MA | ||||||||
| PostalCode: | 021182308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6176387470 | ||||||||
| FaxNumber: | 6176387449 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/22/2005 | ||||||||
| LastUpdateDate: | 06/05/2014 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 59050 | MA | N | Allopathic & Osteopathic Physicians | Internal Medicine | 207RE0101X | 59050 | MA | Y | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
| ID | Type | State | Issuer | Description | 3031977 | 05 | MA | MEDICAID | 110045432A | 05 | MA | MEDICAID |