Provider Demographics
NPI:1871538124
Name:LEE, WON KYU (MD)
Entity type:Individual
Prefix:DR
First Name:WON
Middle Name:KYU
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2650 HORIZON DR SE
Mailing Address - Street 2:SUITE 233
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7686
Mailing Address - Country:US
Mailing Address - Phone:616-419-3607
Mailing Address - Fax:616-419-3679
Practice Address - Street 1:2650 HORIZON DR SE
Practice Address - Street 2:SUITE 233
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-7686
Practice Address - Country:US
Practice Address - Phone:616-419-3607
Practice Address - Fax:616-419-3679
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-19
Last Update Date:2016-01-26
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CAC43108207N00000X, 207ZD0900X, 207ZP0102X
MI4301065083207ZD0900X, 207ZP0102X
AZ36275207ZD0900X, 207ZP0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207ZD0900XAllopathic & Osteopathic PhysiciansPathologyDermatopathology
No207N00000XAllopathic & Osteopathic PhysiciansDermatology
No207ZP0102XAllopathic & Osteopathic PhysiciansPathologyAnatomic Pathology & Clinical Pathology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAEA620AMedicare PIN
AZZ146911Medicare PIN
MIMI5681Medicare PIN