Provider Demographics
NPI:1376642405
Name:LEE, KYUNG CHUL (M D,)
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:CHUL
Last Name:LEE
Suffix:
Gender:M
Credentials:M D,
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:292 MOUNT HOPE RD
Mailing Address - Street 2:
Mailing Address - City:SOMERSET
Mailing Address - State:MA
Mailing Address - Zip Code:02726-3639
Mailing Address - Country:US
Mailing Address - Phone:508-673-1799
Mailing Address - Fax:401-847-5767
Practice Address - Street 1:67 VALLEY RD
Practice Address - Street 2:
Practice Address - City:MIDDLETOWN
Practice Address - State:RI
Practice Address - Zip Code:02842-7218
Practice Address - Country:US
Practice Address - Phone:401-847-4950
Practice Address - Fax:401-847-5767
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RI5246207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA3051927Medicaid
E-15240Medicare UPIN
MA3051927Medicaid