Provider Demographics
NPI:1831371566
Name:LEE, MARK EUNGSANG (PT)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:EUNGSANG
Last Name:LEE
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1608 LEMOINE AVE
Mailing Address - Street 2:STE 202
Mailing Address - City:FORT LEE
Mailing Address - State:NJ
Mailing Address - Zip Code:07024-5636
Mailing Address - Country:US
Mailing Address - Phone:201-894-5451
Mailing Address - Fax:201-334-0068
Practice Address - Street 1:1608 LEMOINE AVE STE 202
Practice Address - Street 2:
Practice Address - City:FORT LEE
Practice Address - State:NJ
Practice Address - Zip Code:07024-5636
Practice Address - Country:US
Practice Address - Phone:018-945-4512
Practice Address - Fax:201-334-0068
Is Sole Proprietor?:No
Enumeration Date:2007-12-05
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ40QA01075900225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ12438VVTMedicare PIN