Provider Demographics
NPI:1336343268
Name:METRO DERMATOLOGY OF NY,PC
Entity Type:Organization
Organization Name:METRO DERMATOLOGY OF NY,PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:HYUN SOO
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:718-886-9000
Mailing Address - Street 1:4012 80TH ST
Mailing Address - Street 2:
Mailing Address - City:ELMHURST
Mailing Address - State:NY
Mailing Address - Zip Code:11373-1234
Mailing Address - Country:US
Mailing Address - Phone:718-886-9000
Mailing Address - Fax:718-961-0666
Practice Address - Street 1:14472 NORTHERN BLVD STE 203
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4231
Practice Address - Country:US
Practice Address - Phone:718-886-9000
Practice Address - Fax:718-961-0666
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-13
Last Update Date:2020-08-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY270019207N00000X
NY191741207N00000X
NY186672207ND0900X
NY258414207ND0900X
NY012705363A00000X
NY012529363A00000X
NY015855363A00000X
NY017384363A00000X
NY017273363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantGroup - Single Specialty
No207N00000XAllopathic & Osteopathic PhysiciansDermatologyGroup - Single Specialty
No207ND0900XAllopathic & Osteopathic PhysiciansDermatologyDermatopathologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYG40004095Medicare UPIN
NYG27514Medicare UPIN
NYG400044095Medicare UPIN
NY04536GMedicare UPIN
NYG400050952Medicare UPIN
NYG400177624Medicare UPIN
NY04536HMedicare PIN
NYF97349Medicare UPIN
NYG400083711Medicare UPIN
NYG400282452Medicare UPIN