Provider Demographics
NPI:1871530840
Name:LEE, KANG K (MD)
Entity type:Individual
Prefix:
First Name:KANG
Middle Name:K
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 1:90 JACKSON PIKE
Mailing Address - Street 2:
Mailing Address - City:GALLIPOLIS
Mailing Address - State:OH
Mailing Address - Zip Code:45631-1560
Mailing Address - Country:US
Mailing Address - Phone:749-446-5371
Mailing Address - Fax:740-446-5711
Practice Address - Street 1:90 JACKSON PIKE
Practice Address - Street 2:
Practice Address - City:GALLIPOLIS
Practice Address - State:OH
Practice Address - Zip Code:45631-1560
Practice Address - Country:US
Practice Address - Phone:749-446-5371
Practice Address - Fax:740-446-5711
Is Sole Proprietor?:No
Enumeration Date:2006-05-31
Last Update Date:2014-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-04-5728208000000X
WV18084208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0431894Medicaid
OH000000181980OtherUNISON MEDICAID
WV0109417000Medicaid
OH0431894OtherMOLINA MEDICAID
000000007615OtherANTHEM BCBS
001714077OtherMOUNTAIN STATE BCBS
370008780OtherRR MEDICARE
OH310917085036OtherOH MEDICAID CARESOURCE
OH310917085036OtherOH MEDICAID CARESOURCE
WV0109417000Medicaid
OH0431894Medicaid