Provider Demographics
NPI:1649056466
Name:SUN IK LEE MD INC A PROFESSIONAL MEDICAL CORPORATION
Entity type:Organization
Organization Name:SUN IK LEE MD INC A PROFESSIONAL MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:SUN IK
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:209-571-0288
Mailing Address - Street 1:PO BOX 36833
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-1210
Mailing Address - Country:US
Mailing Address - Phone:209-571-0288
Mailing Address - Fax:209-571-0327
Practice Address - Street 1:4016 DALE RD
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95356-9268
Practice Address - Country:US
Practice Address - Phone:209-571-2088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-06
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological SurgeryGroup - Single Specialty