Provider Demographics
NPI:1811966880
Name:LEE-KWEN, PETERKIN (MD)
Entity type:Individual
Prefix:
First Name:PETERKIN
Middle Name:
Last Name:LEE-KWEN
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 1:3775 SENECA ST
Mailing Address - Street 2:
Mailing Address - City:WEST SENECA
Mailing Address - State:NY
Mailing Address - Zip Code:14224-3434
Mailing Address - Country:US
Mailing Address - Phone:716-712-0890
Mailing Address - Fax:719-712-0933
Practice Address - Street 1:3775 SENECA ST
Practice Address - Street 2:
Practice Address - City:WEST SENECA
Practice Address - State:NY
Practice Address - Zip Code:14224-3434
Practice Address - Country:US
Practice Address - Phone:716-712-0890
Practice Address - Fax:719-712-0933
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2009-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2069502084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY01721420Medicaid
NYRA5905Medicare ID - Type Unspecified
NY01721420Medicaid