Provider Demographics
NPI:1114012796
Name:LEE, SUNG W (MD)
Entity Type:Individual
Prefix:
First Name:SUNG
Middle Name:W
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 1:6 EASTENTRY RD
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10304-1105
Mailing Address - Country:US
Mailing Address - Phone:718-351-1418
Mailing Address - Fax:718-351-7378
Practice Address - Street 1:6 EASTENTRY RD
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10304-1105
Practice Address - Country:US
Practice Address - Phone:718-351-1418
Practice Address - Fax:718-351-7378
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY109957208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00195666Medicaid
625101Medicare ID - Type Unspecified
NY00195666Medicaid