Provider Demographics
NPI: | 1710908322 |
---|---|
Name: | LEE, KIWON (MD) |
Entity Type: | Individual |
Prefix: | DR |
First Name: | KIWON |
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: | 6400 FANNIN ST STE 2070 |
Mailing Address - Street 2: | |
Mailing Address - City: | HOUSTON |
Mailing Address - State: | TX |
Mailing Address - Zip Code: | 77030-1541 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 713-704-6731 |
Mailing Address - Fax: | 710-704-6889 |
Practice Address - Street 1: | 6400 FANNIN ST STE 2800 |
Practice Address - Street 2: | |
Practice Address - City: | HOUSTON |
Practice Address - State: | TX |
Practice Address - Zip Code: | 77030-1534 |
Practice Address - Country: | US |
Practice Address - Phone: | 713-704-7100 |
Practice Address - Fax: | 710-704-7150 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-07-21 |
Last Update Date: | 2014-08-27 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
TX | P2717 | 2084N0400X, 207RC0200X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 207RC0200X | Allopathic & Osteopathic Physicians | Internal Medicine | Critical Care Medicine |
No | 2084N0400X | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
TX | 302502501 | Medicaid | |
TX | 8DJ101 | Other | BCBSTX PROV REC # |
TX | 302502501 | Medicaid |