Healthcare Provider Details

I. General information

NPI: 1104142793
Provider Name (Legal Business Name): WALTER KOREA LEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/08/2010
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9139 RIDGELINE BLVD
HIGHLANDS RANCH CO
80129-2333
US

IV. Provider business mailing address

10350 E DAKOTA AVE
DENVER CO
80247-1314
US

V. Phone/Fax

Practice location:
  • Phone: 303-338-4545
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberDR.0052094
License Number StateCO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier24273741
Identifier TypeMEDICAID
Identifier StateCO
Identifier Issuer
# 2
Identifier028912
Identifier TypeOTHER
Identifier StateCO
Identifier IssuerKAISER COMMERCIAL NUMBER

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: