Provider Demographics
NPI:1194753319
Name:LEE, SONG YOUNG (MD)
Entity type:Individual
Prefix:DR
First Name:SONG
Middle Name:YOUNG
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:6220 COLLEYVILLE BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:COLLEYVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:76034-6278
Mailing Address - Country:US
Mailing Address - Phone:817-416-0525
Mailing Address - Fax:817-416-5831
Practice Address - Street 1:6220 COLLEYVILLE BLVD
Practice Address - Street 2:SUITE B
Practice Address - City:COLLEYVILLE
Practice Address - State:TX
Practice Address - Zip Code:76034-6278
Practice Address - Country:US
Practice Address - Phone:817-416-0525
Practice Address - Fax:817-416-5831
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-28
Last Update Date:2024-11-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
TXK6877207QA0505X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
G46047Medicare UPIN
00720PMedicare ID - Type Unspecified