Provider Demographics
NPI:1174953913
Name:LEE, SUNG AE (MD)
Entity type:Individual
Prefix:
First Name:SUNG
Middle Name:AE
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 1:820 W. RAVINA LANE
Mailing Address - Street 2:
Mailing Address - City:ANTHEM
Mailing Address - State:AZ
Mailing Address - Zip Code:85086
Mailing Address - Country:US
Mailing Address - Phone:623-433-9904
Mailing Address - Fax:623-433-9904
Practice Address - Street 1:820 W. RAVINA LANE
Practice Address - Street 2:
Practice Address - City:ANTHEM
Practice Address - State:AZ
Practice Address - Zip Code:85086
Practice Address - Country:US
Practice Address - Phone:623-433-9904
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-14
Last Update Date:2013-11-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK101882085R0001X
MO331312085R0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0001XAllopathic & Osteopathic PhysiciansRadiologyRadiation Oncology