Provider Demographics
NPI:1558412270
Name:LEE, SEUNGWOO
Entity Type:Individual
Prefix:
First Name:SEUNGWOO
Middle Name:
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 1:23 MICHELE LN
Mailing Address - Street 2:
Mailing Address - City:HAUPPAUGE
Mailing Address - State:NY
Mailing Address - Zip Code:11788-3329
Mailing Address - Country:US
Mailing Address - Phone:631-724-3429
Mailing Address - Fax:
Practice Address - Street 1:131 MERRICK AVE
Practice Address - Street 2:
Practice Address - City:MERRICK
Practice Address - State:NY
Practice Address - Zip Code:11566-3147
Practice Address - Country:US
Practice Address - Phone:516-378-0119
Practice Address - Fax:516-378-5210
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-16
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY028938183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00378092Medicaid
NY0705240001Medicare NSC