Provider Demographics
NPI:1750462198
Name:LEE, PETER KISUK (MD, PHD)
Entity Type:Individual
Prefix:
First Name:PETER
Middle Name:KISUK
Last Name:LEE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2116 CRAIG RD
Mailing Address - Street 2:MMC - EAU CLAIRE MEDICAL OFFICES
Mailing Address - City:EAU CLAIRE
Mailing Address - State:WI
Mailing Address - Zip Code:54701-6149
Mailing Address - Country:US
Mailing Address - Phone:715-858-4500
Mailing Address - Fax:715-858-4502
Practice Address - Street 1:2116 CRAIG RD
Practice Address - Street 2:MMC - EAU CLAIRE MEDICAL OFFICES
Practice Address - City:EAU CLAIRE
Practice Address - State:WI
Practice Address - Zip Code:54701-6149
Practice Address - Country:US
Practice Address - Phone:715-858-4500
Practice Address - Fax:715-858-4502
Is Sole Proprietor?:No
Enumeration Date:2006-10-18
Last Update Date:2021-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN40742207N00000X, 207ND0101X
WI20286207ND0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ND0101XAllopathic & Osteopathic PhysiciansDermatologyMOHS-Micrographic Surgery
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN121915OtherUCARE
MN656310OtherARAZ
MN03-00010OtherMEDICA-PRIMARY
IA0512590Medicaid
070012427OtherRR MEDICARE
MN383318600Medicaid
MN0300035OtherMEDICA-CHOICE
MN656310OtherFAIRVIEW
MN1018635OtherPREFERRED ONE
MN11G68LEOtherBCBS
MNHP27293OtherHEALTH PARTNERS
070012427OtherRR MEDICARE
MN11G68LEOtherBCBS