Provider Demographics
NPI:1053330894
Name:LEE, SONTAEK THEODORE (MD)
Entity Type:Individual
Prefix:
First Name:SONTAEK
Middle Name:THEODORE
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 1:11217 LOCKWOOD DR
Mailing Address - Street 2:
Mailing Address - City:SILVER SPRING
Mailing Address - State:MD
Mailing Address - Zip Code:20901-4550
Mailing Address - Country:US
Mailing Address - Phone:301-681-7712
Mailing Address - Fax:301-681-7734
Practice Address - Street 1:11217 LOCKWOOD DR
Practice Address - Street 2:
Practice Address - City:SILVER SPRING
Practice Address - State:MD
Practice Address - Zip Code:20901-4550
Practice Address - Country:US
Practice Address - Phone:301-681-7712
Practice Address - Fax:301-681-7734
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-19
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0014522207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6280366Medicaid
MDD0014522OtherSTATE LICENSE
BL0371207OtherDEA
VA6280366Medicaid
MDD0014522OtherSTATE LICENSE