Provider Demographics
NPI:1386806685
Name:LEE, BO RYUNG (MD)
Entity type:Individual
Prefix:
First Name:BO RYUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2690 HAMILTON MILL RD
Mailing Address - Street 2:STE 100
Mailing Address - City:BUFORD
Mailing Address - State:GA
Mailing Address - Zip Code:30519-4105
Mailing Address - Country:US
Mailing Address - Phone:470-326-7300
Mailing Address - Fax:
Practice Address - Street 1:2690 HAMILTON MILL RD
Practice Address - Street 2:STE 100
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4105
Practice Address - Country:US
Practice Address - Phone:470-326-7300
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-27
Last Update Date:2016-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA62868207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA202I088078Medicare UPIN