Provider Demographics
NPI:1679159776
Name:LEE, JUSTIN BLAKE (MD)
Entity type:Individual
Prefix:DR
First Name:JUSTIN
Middle Name:BLAKE
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CABELA DR
Mailing Address - Street 2:
Mailing Address - City:TRIADELPHIA
Mailing Address - State:WV
Mailing Address - Zip Code:26059-1044
Mailing Address - Country:US
Mailing Address - Phone:681-618-1011
Mailing Address - Fax:
Practice Address - Street 1:500 CABELA DR
Practice Address - Street 2:
Practice Address - City:TRIADELPHIA
Practice Address - State:WV
Practice Address - Zip Code:26059-1044
Practice Address - Country:US
Practice Address - Phone:681-618-1011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-20
Last Update Date:2024-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program