Provider Demographics
NPI:1457394306
Name:LEE, JUNG LACK (MD)
Entity Type:Individual
Prefix:
First Name:JUNG
Middle Name:LACK
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 1:341 POWELL ST.
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10312
Mailing Address - Country:US
Mailing Address - Phone:718-966-6000
Mailing Address - Fax:718-966-2576
Practice Address - Street 1:143-25A ROOSEVELT AVE.
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354
Practice Address - Country:US
Practice Address - Phone:718-353-0505
Practice Address - Fax:718-966-2576
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2014-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY144342208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY00823818Medicaid
NY00823818Medicaid
C06241Medicare UPIN