Provider Demographics
NPI:1700927001
Name:KWANG J LEE MD PROFESSIONAL CORPORATION
Entity type:Organization
Organization Name:KWANG J LEE MD PROFESSIONAL CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER PHYSICIAN
Authorized Official - Prefix:DR
Authorized Official - First Name:KWANG
Authorized Official - Middle Name:J
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:702-732-4500
Mailing Address - Street 1:6980 SMOKE RANCH RD
Mailing Address - Street 2:STE 110
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89128-8605
Mailing Address - Country:US
Mailing Address - Phone:702-732-4500
Mailing Address - Fax:702-818-1393
Practice Address - Street 1:6980 SMOKE RANCH RD
Practice Address - Street 2:STE 110
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89128-8605
Practice Address - Country:US
Practice Address - Phone:702-732-4500
Practice Address - Fax:702-818-1393
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-09
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV6811207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV002019317Medicaid
NV002019317Medicaid