Provider Demographics
NPI:1003976077
Name:LEE, KEVIN S (MD)
Entity Type:Individual
Prefix:
First Name:KEVIN
Middle Name:S
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 1:1649 DEER PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:DEER PARK
Mailing Address - State:NY
Mailing Address - Zip Code:11729
Mailing Address - Country:US
Mailing Address - Phone:631-667-8178
Mailing Address - Fax:631-667-3859
Practice Address - Street 1:1649 DEER PARK AVENUE
Practice Address - Street 2:
Practice Address - City:DEER PARK
Practice Address - State:NY
Practice Address - Zip Code:11729
Practice Address - Country:US
Practice Address - Phone:631-667-8178
Practice Address - Fax:631-667-3859
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186405207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01665998Medicaid
G00734Medicare UPIN
NY01665998Medicaid