Provider Demographics
NPI:1285734285
Name:LEE, BOHYUNG KEN (MD)
Entity type:Individual
Prefix:
First Name:BOHYUNG
Middle Name:KEN
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 1:1502 COUNTRY CLUB DR E
Mailing Address - Street 2:
Mailing Address - City:WARSAW
Mailing Address - State:IN
Mailing Address - Zip Code:46580-5013
Mailing Address - Country:US
Mailing Address - Phone:574-269-1242
Mailing Address - Fax:
Practice Address - Street 1:7950 W JEFFERSON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4140
Practice Address - Country:US
Practice Address - Phone:260-435-7001
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-09-22
Last Update Date:2008-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01037341207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN138420BBBMedicare ID - Type Unspecified
INE19741Medicare UPIN