Provider Demographics
NPI:1033134267
Name:LEE, EDWARD SUNGWON (DO)
Entity Type:Individual
Prefix:
First Name:EDWARD
Middle Name:SUNGWON
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:PO BOX 5127
Mailing Address - Street 2:
Mailing Address - City:EVERETT
Mailing Address - State:WA
Mailing Address - Zip Code:98206-5127
Mailing Address - Country:US
Mailing Address - Phone:425-304-8431
Mailing Address - Fax:
Practice Address - Street 1:11800 NE 128TH ST FL 5
Practice Address - Street 2:
Practice Address - City:KIRKLAND
Practice Address - State:WA
Practice Address - Zip Code:98034-7208
Practice Address - Country:US
Practice Address - Phone:425-899-5200
Practice Address - Fax:425-899-5204
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109991207Q00000X
WAOP60219951207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL834340022OtherMEDICARE PTAN
IL834340OtherMEDICARE GROUP PTAN
IL834370OtherMEDICARE GROUP #
ILH73249Medicare UPIN
ILK02569Medicare PIN
WAG8904054Medicare UPIN
IL834370OtherMEDICARE GROUP #
ILCC5050Medicare ID - Type UnspecifiedRR GROUP #
ILH73249Medicare UPIN
IL834330Medicare ID - Type UnspecifiedMEDICARE GROUP #
IL834340Medicare ID - Type UnspecifiedMEDICARE GROUP #
ILK02569Medicare PIN