Provider Demographics
NPI:1144379587
Name:LEE, GONGJA KIM
Entity Type:Individual
Prefix:
First Name:GONGJA
Middle Name:KIM
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:153 12TH ST
Mailing Address - Street 2:
Mailing Address - City:CRESSKILL
Mailing Address - State:NJ
Mailing Address - Zip Code:07626-2403
Mailing Address - Country:US
Mailing Address - Phone:201-569-0258
Mailing Address - Fax:
Practice Address - Street 1:506 MALCOLM X BLVD
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10037-1802
Practice Address - Country:US
Practice Address - Phone:212-939-8070
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-08
Last Update Date:2024-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY0287111835X0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1835X0200XPharmacy Service ProvidersPharmacistOncology