Provider Demographics
NPI:1861479891
Name:LEE, EUI-DONG (MD)
Entity Type:Individual
Prefix:
First Name:EUI-DONG
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 1:601 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5341
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:269-341-8743
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-4407
Practice Address - Fax:269-657-0965
Is Sole Proprietor?:No
Enumeration Date:2005-12-30
Last Update Date:2009-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301032196208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI700H060020OtherBCBSM
MI1861479891Medicaid
MI104994926Medicaid
MI0H06012016Medicare PIN
MI104994926Medicaid