Provider Demographics
NPI:1063476398
Name:LEE, SOO GIL (MD)
Entity Type:Individual
Prefix:DR
First Name:SOO
Middle Name:GIL
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 1:5010 ST HWY 30
Mailing Address - Street 2:STE 201
Mailing Address - City:AMSTERDAM
Mailing Address - State:NY
Mailing Address - Zip Code:12010
Mailing Address - Country:US
Mailing Address - Phone:518-842-7161
Mailing Address - Fax:518-842-0797
Practice Address - Street 1:5010 ST HWY 30
Practice Address - Street 2:STE 201
Practice Address - City:AMSTERDAM
Practice Address - State:NY
Practice Address - Zip Code:12010
Practice Address - Country:US
Practice Address - Phone:518-842-7161
Practice Address - Fax:518-842-0797
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-13
Last Update Date:2013-05-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY161341207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01220319Medicaid
NYCC4535Medicare ID - Type Unspecified
NY01220319Medicaid