Healthcare Provider Details

I. General information

NPI: 1871538124
Provider Name (Legal Business Name): WON KYU LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2006
Last Update Date: 01/26/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2650 HORIZON DR SE SUITE 233
GRAND RAPIDS MI
49546-7686
US

IV. Provider business mailing address

2650 HORIZON DR SE SUITE 233
GRAND RAPIDS MI
49546-7686
US

V. Phone/Fax

Practice location:
  • Phone: 616-419-3607
  • Fax: 616-419-3679
Mailing address:
  • Phone: 616-419-3607
  • Fax: 616-419-3679

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberC43108
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License NumberC43108
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number4301065083
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code207ZD0900X
TaxonomyDermatopathology (Pathology) Physician
License Number36275
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License NumberC43108
License Number StateCA
# 6
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number4301065083
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code207ZP0102X
TaxonomyAnatomic Pathology & Clinical Pathology Physician
License Number36275
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: