Provider Demographics
NPI:1972035103
Name:LEE, SANG IL (MD)
Entity Type:Individual
Prefix:
First Name:SANG IL
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 1:15 CLEARMEADOW LN
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:NY
Mailing Address - Zip Code:11797-1115
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2280A N OCEAN AVE
Practice Address - Street 2:
Practice Address - City:FARMINGVILLE
Practice Address - State:NY
Practice Address - Zip Code:11738-2911
Practice Address - Country:US
Practice Address - Phone:631-698-7828
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-28
Last Update Date:2020-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306776207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine