Provider Demographics
NPI:1093718249
Name:LEE, CHUNG SENG (MD)
Entity Type:Individual
Prefix:
First Name:CHUNG
Middle Name:SENG
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 1:2622 LAKE AVE
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46805-5410
Mailing Address - Country:US
Mailing Address - Phone:260-425-3100
Mailing Address - Fax:260-425-3604
Practice Address - Street 1:2622 LAKE AVE
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46805-5410
Practice Address - Country:US
Practice Address - Phone:260-425-3100
Practice Address - Fax:260-425-3604
Is Sole Proprietor?:No
Enumeration Date:2005-05-23
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01029687A207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100055070Medicaid
IN110002008OtherRR MEDICARE
OH0480939Medicaid
OH0480939Medicaid
INM400033995Medicare PIN