Provider Demographics
NPI:1528069507
Name:LEE, SU-JU (MD)
Entity type:Individual
Prefix:
First Name:SU-JU
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:PO BOX 636256 CENTRAL CREDENTIALING
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45263-6256
Mailing Address - Country:US
Mailing Address - Phone:513-245-3107
Mailing Address - Fax:513-585-5511
Practice Address - Street 1:234 GOODMAN AVENUE
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219
Practice Address - Country:US
Practice Address - Phone:513-584-5335
Practice Address - Fax:513-584-3663
Is Sole Proprietor?:No
Enumeration Date:2005-08-02
Last Update Date:2020-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35058343L2085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0864015Medicaid
KY64875330Medicaid
IN100211910Medicaid
IN100211910Medicaid
OH0864015Medicaid
OH4177093Medicare PIN
OH4177091Medicare PIN
OH4177094Medicare PIN
OH4177092Medicare PIN