Basic Information
| Provider Information | |||||||||
| NPI: | 1003802182 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SANG | ||||||||
| MiddleName: | H. | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 7900 NW 23RD ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730084961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052417745 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 7900 NW 23RD ST | ||||||||
| Address2: | SUITE 1 | ||||||||
| City: | BETHANY | ||||||||
| State: | OK | ||||||||
| PostalCode: | 730084961 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4052417745 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/23/2005 | ||||||||
| LastUpdateDate: | 07/23/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207PE0004X | 3864 | OK | Y | Allopathic & Osteopathic Physicians | Emergency Medicine | Emergency Medical Services | 207P00000X | 3864 | OK | N | Allopathic & Osteopathic Physicians | Emergency Medicine |
ID Information
| ID | Type | State | Issuer | Description | 100113780E | 05 | OK | MEDICAID |