Provider Demographics
NPI:1104205103
Name:LEE, DAE YONG (DPM)
Entity Type:Individual
Prefix:DR
First Name:DAE
Middle Name:YONG
Last Name:LEE
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12 N 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:NY
Mailing Address - Zip Code:10550-2026
Mailing Address - Country:US
Mailing Address - Phone:914-664-8000
Mailing Address - Fax:
Practice Address - Street 1:12 N 7TH AVE
Practice Address - Street 2:
Practice Address - City:MOUNT VERNON
Practice Address - State:NY
Practice Address - Zip Code:10550-2026
Practice Address - Country:US
Practice Address - Phone:914-664-8000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-05-22
Last Update Date:2018-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYN006931213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist