Basic Information
Provider Information
NPI: 1003802182
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEE
FirstName: SANG
MiddleName: H.
NamePrefix:  
NameSuffix:  
Credential: D.O.
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
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
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: M
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207P00000X3864OKN Allopathic & Osteopathic PhysiciansEmergency Medicine 
207PE0004X3864OKY Allopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services

ID Information
IDTypeStateIssuerDescription
100113780E05OK MEDICAID


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