Provider Demographics
NPI:1689646259
Name:LEE, JAE SUNG (MD)
Entity type:Individual
Prefix:MR
First Name:JAE
Middle Name:SUNG
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 1:5290 MILITARY RD
Mailing Address - Street 2:STE 6
Mailing Address - City:LEWISTON
Mailing Address - State:NY
Mailing Address - Zip Code:14092
Mailing Address - Country:US
Mailing Address - Phone:716-297-2998
Mailing Address - Fax:
Practice Address - Street 1:5300 MILITARY RD
Practice Address - Street 2:MOUNT ST MARYS HOSPITAL
Practice Address - City:LEWISTON
Practice Address - State:NY
Practice Address - Zip Code:14092
Practice Address - Country:US
Practice Address - Phone:716-297-4800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-07
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY130958207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00589579Medicaid
B36107Medicare UPIN
NY00589579Medicaid