Provider Demographics
NPI:1689756116
Name:LEE, WAN SOO (MD)
Entity Type:Individual
Prefix:
First Name:WAN
Middle Name:SOO
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 1:1802A CORPORAL KENNEDY ST
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11360-1447
Mailing Address - Country:US
Mailing Address - Phone:718-961-6222
Mailing Address - Fax:718-961-6266
Practice Address - Street 1:14431 41ST AVE
Practice Address - Street 2:SUITE L8
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11355-1459
Practice Address - Country:US
Practice Address - Phone:718-961-6222
Practice Address - Fax:718-961-6266
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY226836208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics