Healthcare Provider Details

I. General information

NPI: 1386099703
Provider Name (Legal Business Name): SANGOUK LEE D.O
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2016
Last Update Date: 06/24/2026
Certification Date: 06/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10001 S EASTERN AVE STE 101
HENDERSON NV
89052-3908
US

IV. Provider business mailing address

PO BOX 33269
PHOENIX AZ
85067-3269
US

V. Phone/Fax

Practice location:
  • Phone: 702-616-5870
  • Fax: 702-616-5895
Mailing address:
  • Phone: 602-406-4786
  • Fax: 916-636-4358

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberDO2755
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License NumberDO2755
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: