Provider Demographics
NPI:1720049067
Name:LEE, EDMUND (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:EDMUND
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5 CUBA HILL RD
Mailing Address - Street 2:
Mailing Address - City:GREENLAWN
Mailing Address - State:NY
Mailing Address - Zip Code:11740-1624
Mailing Address - Country:US
Mailing Address - Phone:631-628-5000
Mailing Address - Fax:631-628-5725
Practice Address - Street 1:1476 DEER PARK AVE STE 2
Practice Address - Street 2:
Practice Address - City:NORTH BABYLON
Practice Address - State:NY
Practice Address - Zip Code:11703-1200
Practice Address - Country:US
Practice Address - Phone:929-403-5190
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-28
Last Update Date:2022-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY210438207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYH25333Medicare UPIN