Healthcare Provider Details

I. General information

NPI: 1215224266
Provider Name (Legal Business Name): IKJAE LEE M.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2011
Last Update Date: 09/18/2020
Certification Date: 09/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

710 W 168TH ST # NI-3
NEW YORK NY
10032-3726
US

IV. Provider business mailing address

710 W 168TH ST # NI-3
NEW YORK NY
10032-3726
US

V. Phone/Fax

Practice location:
  • Phone: 212-305-6788
  • Fax: 212-305-1504
Mailing address:
  • Phone: 212-305-6788
  • Fax: 212-305-1504

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License NumberMD.34939
License Number StateAL
# 2
Primary TaxonomyY
Taxonomy Code2084N0008X
TaxonomyNeuromuscular Medicine (Psychiatry & Neurology) Physician
License Number304067
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: