MEDICARE: DR. WON KYU LEE MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	C43108	CA
2	207ZD0900X	Dermatopathology (Pathology) Physician	C43108	CA
3	207ZD0900X	Dermatopathology (Pathology) Physician	4301065083	MI
4	207ZD0900X	Dermatopathology (Pathology) Physician	36275	AZ
5	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	C43108	CA
6	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	4301065083	MI
7	207ZP0102X	Anatomic Pathology & Clinical Pathology Physician	36275	AZ

General Provider Information

NPI Number	:	1871538124
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. WON KYU LEE MD

Provider Business Mailing Address
First Line	:	2650 HORIZON DR SE
Second Line	:	SUITE 233
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-7686
Country	:	US
Telephone Number	:	616-419-3607
Fax Number	:	616-419-3679

Provider Business Practice Location Address
First Line	:	2650 HORIZON DR SE
Second Line	:	SUITE 233
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-7686
Country	:	US
Telephone Number	:	616-419-3607
Fax Number	:	616-419-3679

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/19/2006
Last Update Date	:	01/26/2016

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Directions to “ DR. WON KYU LEE MD” Practice Location

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