Provider Demographics
NPI:1053007955
Name:LEE, MASON JOSEPH (DO)
Entity type:Individual
Prefix:
First Name:MASON
Middle Name:JOSEPH
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 DEER RUN E
Mailing Address - Street 2:
Mailing Address - City:POCAHONTAS
Mailing Address - State:IL
Mailing Address - Zip Code:62275-1543
Mailing Address - Country:US
Mailing Address - Phone:618-979-6543
Mailing Address - Fax:
Practice Address - Street 1:12680 OLIVE BLVD STE 300
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6322
Practice Address - Country:US
Practice Address - Phone:314-251-8888
Practice Address - Fax:314-251-8889
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-13
Last Update Date:2023-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023019906207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine