Healthcare Provider Details

I. General information

NPI: 1871880864
Provider Name (Legal Business Name): BOOYONG HA LEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/29/2011
Last Update Date: 06/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

107 HICKORY ROAD
BRIARCLIFF MANOR NY
10510
US

IV. Provider business mailing address

107 HICKORY ROAD
BRIARCLIFF MANOR NY
10510
US

V. Phone/Fax

Practice location:
  • Phone: 914-373-4241
  • Fax: 914-373-4241
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number116443
License Number StateNY

VII. Legacy identifiers

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

# 1
Identifier00215614
Identifier TypeMEDICAID
Identifier StateNY
Identifier Issuer

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: