Provider Demographics
NPI:1730264797
Name:LEE, SUSIE KIM (MD)
Entity type:Individual
Prefix:DR
First Name:SUSIE
Middle Name:KIM
Last Name:LEE
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 1:4422 3RD AVE
Mailing Address - Street 2:DEPARTMENT OF MEDICINE
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10457-2545
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4422 3RD AVE
Practice Address - Street 2:DEPARTMENT OF MEDICINE
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2545
Practice Address - Country:US
Practice Address - Phone:718-960-6205
Practice Address - Fax:718-960-3218
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY207553207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02266824Medicaid
NYH55153Medicare UPIN
NY02266824Medicaid