Provider Demographics
NPI:1710908322
Name:LEE, KIWON (MD)
Entity type:Individual
Prefix:DR
First Name:KIWON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
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:PO BOX 416457
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02241-6457
Mailing Address - Country:US
Mailing Address - Phone:713-704-6731
Mailing Address - Fax:
Practice Address - Street 1:99 BEAUVOIR AVE
Practice Address - Street 2:
Practice Address - City:SUMMIT
Practice Address - State:NJ
Practice Address - Zip Code:07901-3533
Practice Address - Country:US
Practice Address - Phone:908-522-2829
Practice Address - Fax:908-522-6417
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2024-06-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXP2717207RC0200X, 2084N0400X
NJ25MA090168002084V0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084V0102XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyVascular Neurology
No207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care Medicine
No2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX8DJ101OtherBCBSTX PROV REC #
TX302502501Medicaid
TX302502501Medicaid