Provider Demographics
NPI:1679508048
Name:LEE, SOO G (MD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:G
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:645 WESTWOOD AVE FL 2
Mailing Address - Street 2:
Mailing Address - City:RIVERVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07675-6238
Mailing Address - Country:US
Mailing Address - Phone:201-358-6774
Mailing Address - Fax:201-358-1140
Practice Address - Street 1:15 VERVALEN ST
Practice Address - Street 2:
Practice Address - City:CLOSTER
Practice Address - State:NJ
Practice Address - Zip Code:07624-2635
Practice Address - Country:US
Practice Address - Phone:201-784-3600
Practice Address - Fax:201-784-5677
Is Sole Proprietor?:No
Enumeration Date:2006-07-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA07426600207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ9116508Medicaid
NJ9116508Medicaid
H51413Medicare UPIN