Provider Demographics
NPI:1558446674
Name:LEE, HYUN-SOO (MD)
Entity Type:Individual
Prefix:
First Name:HYUN-SOO
Middle Name:
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 1:4012 80TH ST STE 5A
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1234
Mailing Address - Country:US
Mailing Address - Phone:718-886-9000
Mailing Address - Fax:718-961-0666
Practice Address - Street 1:14472 NORTHERN BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4231
Practice Address - Country:US
Practice Address - Phone:718-886-9000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2022-03-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY186672207ND0900X, 207NP0225X, 207NS0135X
NJMA66379207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathology
No207NP0225XAllopathic & Osteopathic PhysiciansDermatologyPediatric Dermatology
No207NS0135XAllopathic & Osteopathic PhysiciansDermatologyProcedural Dermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01761279Medicaid
NJ7458703Medicaid
NJ7458703Medicaid
NY01761279Medicaid
NJ084635Medicare ID - Type Unspecified