Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207QA0505X | Family Doctor - Adult Medicine | K6877 | TX |
NPI | 1194753319 |
---|---|
Provider Name | Dr. Song Young Lee |
First Address | Colleyville, TX 76034-6278 |
Second Address | Colleyville, TX 76034-6278 |
Gender | M |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/06/2006 |
Last Update Date | 04/03/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
G46047 | (02) |