Provider Demographics
NPI:1255847935
Name:LEE, GWANGJONG DANNY
Entity Type:Individual
Prefix:DR
First Name:GWANGJONG
Middle Name:DANNY
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1817 W 5TH ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51103-3434
Mailing Address - Country:US
Mailing Address - Phone:712-259-0384
Mailing Address - Fax:
Practice Address - Street 1:105 E MADISON ST
Practice Address - Street 2:
Practice Address - City:WINTERSET
Practice Address - State:IA
Practice Address - Zip Code:50273-2412
Practice Address - Country:US
Practice Address - Phone:515-462-4644
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-18
Last Update Date:2017-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA089708111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor