Provider Demographics
NPI:1083158273
Name:LEE, KYUNG JA (MD)
Entity Type:Individual
Prefix:
First Name:KYUNG JA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 THIRD AVE.
Mailing Address - Street 2:SUITE 1069
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11217
Mailing Address - Country:US
Mailing Address - Phone:212-246-3111
Mailing Address - Fax:
Practice Address - Street 1:115 EAST 57 ST.
Practice Address - Street 2:SUITE 1540
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10022
Practice Address - Country:US
Practice Address - Phone:212-246-3111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-12-07
Last Update Date:2016-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY132307207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine