Healthcare Provider Details

I. General information

NPI: 1871751065
Provider Name (Legal Business Name): LAN NA LEE M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/25/2008
Last Update Date: 05/17/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

STONYBROOK UNIVERSITY MEDICAL CTR DEPARTMENT OF OBSTETRICS AND GYNECOLOGY
STONY BROOK NY
11794-0001
US

IV. Provider business mailing address

30 PIEDMONT DR APT 15
PORT JEFFERSON STATION NY
11776-1117
US

V. Phone/Fax

Practice location:
  • Phone: 631-444-4686
  • Fax:
Mailing address:
  • Phone: 917-992-2051
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License NumberA 117279
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number257558
License Number StateNY
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: