Provider Demographics
NPI:1194772418
Name:LEE, SAMUEL SHIN KWON (MD)
Entity type:Individual
Prefix:DR
First Name:SAMUEL
Middle Name:SHIN KWON
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18400 US HIGHWAY 18
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92307-2306
Mailing Address - Country:US
Mailing Address - Phone:760-242-3939
Mailing Address - Fax:760-242-3232
Practice Address - Street 1:18400 US HIGHWAY 18
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-2306
Practice Address - Country:US
Practice Address - Phone:760-242-3939
Practice Address - Fax:760-242-3232
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-30
Last Update Date:2012-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110101208800000X
GA060213208800000X
CAA49819208800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208800000XAllopathic & Osteopathic PhysiciansUrology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO785000022OtherMEDICARE PART B
CADL652YMedicare PIN
CADL652ZMedicare PIN