Provider Demographics
NPI:1720007487
Name:LEE, SOO JUNG (MD)
Entity Type:Individual
Prefix:
First Name:SOO
Middle Name:JUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1125 7TH AVE
Mailing Address - Street 2:
Mailing Address - City:BEAVER FALLS
Mailing Address - State:PA
Mailing Address - Zip Code:15010-4426
Mailing Address - Country:US
Mailing Address - Phone:724-773-8980
Mailing Address - Fax:
Practice Address - Street 1:1125 7TH AVE
Practice Address - Street 2:
Practice Address - City:BEAVER FALLS
Practice Address - State:PA
Practice Address - Zip Code:15010-4426
Practice Address - Country:US
Practice Address - Phone:724-773-8980
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2014-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200401527207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904420Medicaid
NC5904420Medicaid