Provider Demographics
NPI:1255498028
Name:LEE, KI NYOUNG (MD)
Entity Type:Individual
Prefix:DR
First Name:KI
Middle Name:NYOUNG
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 1:9806 SORREL AVE
Mailing Address - Street 2:
Mailing Address - City:POTOMAC
Mailing Address - State:MD
Mailing Address - Zip Code:20854
Mailing Address - Country:US
Mailing Address - Phone:301-299-8160
Mailing Address - Fax:
Practice Address - Street 1:3947 FERRARA DRIVE
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:MD
Practice Address - Zip Code:20906-4709
Practice Address - Country:US
Practice Address - Phone:301-942-9004
Practice Address - Fax:301-942-9004
Is Sole Proprietor?:No
Enumeration Date:2007-01-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0023473207LP2900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207LP2900XAllopathic & Osteopathic PhysiciansAnesthesiologyPain Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
555625OtherAETNA
MD975221800Medicaid
E74568Medicare UPIN
MD975221800Medicaid