Healthcare Provider Details

I. General information

NPI: 1750462198
Provider Name (Legal Business Name): PETER KISUK LEE MD, PHD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 12/21/2021
Certification Date: 12/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 CRAIG RD MMC - EAU CLAIRE MEDICAL OFFICES
EAU CLAIRE WI
54701-6149
US

IV. Provider business mailing address

2116 CRAIG RD MMC - EAU CLAIRE MEDICAL OFFICES
EAU CLAIRE WI
54701-6149
US

V. Phone/Fax

Practice location:
  • Phone: 715-858-4500
  • Fax: 715-858-4502
Mailing address:
  • Phone: 715-858-4500
  • Fax: 715-858-4502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number40742
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number40742
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code207ND0101X
TaxonomyMOHS-Micrographic Surgery Physician
License Number20286
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: