Healthcare Provider Details

I. General information

NPI: 1316473648
Provider Name (Legal Business Name): KYU-IN LEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/05/2017
Last Update Date: 06/21/2024
Certification Date: 06/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24 ELM ST
HARRINGTON PARK NJ
07640-1902
US

IV. Provider business mailing address

24 ELM ST
HARRINGTON PARK NJ
07640-1902
US

V. Phone/Fax

Practice location:
  • Phone: 201-784-0123
  • Fax:
Mailing address:
  • Phone: 201-784-0123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code207RR0500X
TaxonomyRheumatology Physician
License Number25MA12219500
License Number StateNJ
# 3
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number303774
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: