Provider Demographics
NPI:1396709457
Name:LEE, SANG O (MD)
Entity type:Individual
Prefix:
First Name:SANG
Middle Name:O
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:804 KENYON ROAD
Mailing Address - Street 2:SUITE A
Mailing Address - City:FORT DODGE
Mailing Address - State:IA
Mailing Address - Zip Code:50501-5742
Mailing Address - Country:US
Mailing Address - Phone:515-574-6120
Mailing Address - Fax:515-574-6135
Practice Address - Street 1:804 KENYON ROAD
Practice Address - Street 2:SUITE A
Practice Address - City:FORT DODGE
Practice Address - State:IA
Practice Address - Zip Code:50501-5742
Practice Address - Country:US
Practice Address - Phone:515-574-6120
Practice Address - Fax:515-574-6135
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-14
Last Update Date:2012-02-20
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IA214562084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0159806Medicaid
IA10198OtherBLUE CROSS BLUE SHIELD
IA10198Medicare ID - Type Unspecified
IA0159806Medicaid