1467420265 NPI number — DR. SUK WAN LEE MD

Table of content: DR. SUK WAN LEE MD (NPI 1467420265)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1467420265 NPI number — DR. SUK WAN LEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
SUK
Provider Middle Name:
WAN
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1467420265
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/05/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3130 N COUNTY ROAD 25A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TROY
Provider Business Mailing Address State Name:
OH
Provider Business Mailing Address Postal Code:
45373-1337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
937-440-7497
Provider Business Mailing Address Fax Number:
937-440-7337

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
998 S DORSET RD
Provider Second Line Business Practice Location Address:
SUITE 206
Provider Business Practice Location Address City Name:
TROY
Provider Business Practice Location Address State Name:
OH
Provider Business Practice Location Address Postal Code:
45373-4753
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
937-332-1165
Provider Business Practice Location Address Fax Number:
937-332-1384
Provider Enumeration Date:
03/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 207RC0000X , with the licence number:  35036869 , registered in the state of OH ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0340876 , issued by the state of ( OH ) . This identifiers is of the category "MEDICAID".




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