Provider Demographics
NPI:1942562103
Name:LEE, JOHN SANGWON (MD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:SANGWON
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:DR
Other - First Name:JOHN
Other - Middle Name:SANGWON
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:99 PIGEON RD
Mailing Address - Street 2:99 PIGEON RD
Mailing Address - City:WILLIMANTIC
Mailing Address - State:CT
Mailing Address - Zip Code:06226-1320
Mailing Address - Country:US
Mailing Address - Phone:860-456-4347
Mailing Address - Fax:
Practice Address - Street 1:99 PIGEON RD
Practice Address - Street 2:
Practice Address - City:WILLIMANTIC
Practice Address - State:CT
Practice Address - Zip Code:06226-1320
Practice Address - Country:US
Practice Address - Phone:860-456-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT016370174H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174H00000XOther Service ProvidersHealth Educator