Provider Demographics
NPI:1114909785
Name:LEE, CHENG CHONG (MD)
Entity Type:Individual
Prefix:
First Name:CHENG CHONG
Middle Name:
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 1:6742 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-2034
Mailing Address - Country:US
Mailing Address - Phone:313-928-2333
Mailing Address - Fax:
Practice Address - Street 1:6742 PARK AVE
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-2034
Practice Address - Country:US
Practice Address - Phone:313-928-2333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-11-18
Last Update Date:2008-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301031562207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1432252Medicaid
D91449Medicare UPIN
MIOM18000005Medicare ID - Type Unspecified