Provider Demographics
NPI:1093874125
Name:LEE, TAY BONG (MD)
Entity Type:Individual
Prefix:DR
First Name:TAY BONG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:TAY B.
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:38 DONNYBROOK DRIVE
Mailing Address - Street 2:
Mailing Address - City:DEMAREST
Mailing Address - State:NJ
Mailing Address - Zip Code:07627-1005
Mailing Address - Country:US
Mailing Address - Phone:201-767-7691
Mailing Address - Fax:201-767-3672
Practice Address - Street 1:30 CENTRAL PARK SOUTH, SUITE 11B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10019-1628
Practice Address - Country:US
Practice Address - Phone:212-759-9614
Practice Address - Fax:212-750-2849
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY115741207Y00000X
NJ25MA02861600207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYB78469Medicare UPIN
NY633491Medicare PIN