Provider Demographics
NPI:1740340116
Name:LEE, HAN SOO (MD)
Entity type:Individual
Prefix:
First Name:HAN
Middle Name:SOO
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:HAN SOO
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3 DELAMAR COURT
Mailing Address - Street 2:
Mailing Address - City:GLEN COVE
Mailing Address - State:NY
Mailing Address - Zip Code:11542-1792
Mailing Address - Country:US
Mailing Address - Phone:516-676-5552
Mailing Address - Fax:
Practice Address - Street 1:221 BROADWAY
Practice Address - Street 2:SUITE 303
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-2747
Practice Address - Country:US
Practice Address - Phone:631-789-7809
Practice Address - Fax:631-789-8571
Is Sole Proprietor?:No
Enumeration Date:2006-12-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY1092442084P0800X, 2084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Not Answered2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent Psychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
694231Medicare ID - Type Unspecified
D79298Medicare UPIN