Provider Demographics
NPI:1336217579
Name:LEE, JOSEPH BONGHYUN (MD)
Entity Type:Individual
Prefix:DR
First Name:JOSEPH
Middle Name:BONGHYUN
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:43 BOTSFORD RD
Mailing Address - Street 2:
Mailing Address - City:CHESTNUT HILL
Mailing Address - State:MA
Mailing Address - Zip Code:02467-3019
Mailing Address - Country:US
Mailing Address - Phone:617-475-0129
Mailing Address - Fax:206-337-1066
Practice Address - Street 1:875 MASSACHUSETTS AVE STE 72
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MA
Practice Address - Zip Code:02139-3071
Practice Address - Country:US
Practice Address - Phone:617-475-0129
Practice Address - Fax:206-337-1066
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-04
Last Update Date:2016-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV218622084P0800X
MA2418302084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810003220Medicaid
I40840Medicare UPIN
WV3810003220Medicaid