Provider Demographics
NPI:1144670639
Name:LEE KIM, MARISA ESTHER (MD)
Entity type:Individual
Prefix:
First Name:MARISA
Middle Name:ESTHER
Last Name:LEE KIM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:61 BRADLEY ST
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-5103
Mailing Address - Country:US
Mailing Address - Phone:860-584-8021
Mailing Address - Fax:
Practice Address - Street 1:61 BRADLEY ST
Practice Address - Street 2:
Practice Address - City:BRISTOL
Practice Address - State:CT
Practice Address - Zip Code:06010-5103
Practice Address - Country:US
Practice Address - Phone:860-584-8021
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-06-15
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT61896207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty