Healthcare Provider Details

I. General information

NPI: 1023252459
Provider Name (Legal Business Name): KYU WON LEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/29/2009
Last Update Date: 04/29/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 KENDALL TER
NEWTON MA
02458-2021
US

IV. Provider business mailing address

19 KENDALL TER
NEWTON MA
02458-2021
US

V. Phone/Fax

Practice location:
  • Phone: 617-965-5026
  • Fax:
Mailing address:
  • Phone: 617-965-5026
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License Number37024
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: