Provider Demographics
NPI:1144296492
Name:LEE, SUNG-WON (MD)
Entity type:Individual
Prefix:
First Name:SUNG-WON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:RYAN
Other - Middle Name:S
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:7 BROAD AVE
Mailing Address - Street 2:SUITE 203
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-1886
Mailing Address - Country:US
Mailing Address - Phone:201-941-2486
Mailing Address - Fax:201-941-1577
Practice Address - Street 1:7 BROAD AVE
Practice Address - Street 2:SUITE 203
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-1886
Practice Address - Country:US
Practice Address - Phone:201-941-2486
Practice Address - Fax:201-941-1577
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2015-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJMA08015300207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0093572Medicaid
NJ0093572Medicaid
NJH71110Medicare UPIN
NJ097252Medicare PIN