Provider Demographics
NPI:1235115429
Name:LEE, MYUNG SOO (MD)
Entity Type:Individual
Prefix:
First Name:MYUNG
Middle Name:SOO
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 1:1601 MILLTOWN RD
Mailing Address - Street 2:SUITE 13
Mailing Address - City:WILMINGTON
Mailing Address - State:DE
Mailing Address - Zip Code:19808-4027
Mailing Address - Country:US
Mailing Address - Phone:302-993-2330
Mailing Address - Fax:302-993-2344
Practice Address - Street 1:L6 OMEGA DR
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713-2077
Practice Address - Country:US
Practice Address - Phone:302-738-9300
Practice Address - Fax:302-738-3791
Is Sole Proprietor?:No
Enumeration Date:2005-12-20
Last Update Date:2012-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC100017882085N0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085N0700XAllopathic & Osteopathic PhysiciansRadiologyNeuroradiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE0000190701Medicaid
DE199144W26Medicare PIN
DE00A568G66Medicare PIN
DE003827D14Medicare PIN
DE199144O31Medicare PIN
DE0000190701Medicaid
DE199144P97Medicare PIN
DEC48733Medicare UPIN
DE199144O73Medicare PIN