Provider Demographics
NPI:1376804757
Name:LEE, SUN IK (MD)
Entity Type:Individual
Prefix:DR
First Name:SUN IK
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:SUN IK
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 36833
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1210
Mailing Address - Country:US
Mailing Address - Phone:209-571-0288
Mailing Address - Fax:209-571-0327
Practice Address - Street 1:4016 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9268
Practice Address - Country:US
Practice Address - Phone:209-571-0288
Practice Address - Fax:209-571-0327
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-01
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LAMD. 203337282N00000X
CAA140655207T00000X
NE27123207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No282N00000XHospitalsGeneral Acute Care Hospital
Provider Identifiers
StateIdentifier IDID TypeIssuer
NE1437184652Medicaid