Provider Demographics
NPI:1538239819
Name:LEE, MIKYUNG (MD)
Entity type:Individual
Prefix:
First Name:MIKYUNG
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 1:7974 UW HEALTH CT
Mailing Address - Street 2:
Mailing Address - City:MIDDLETON
Mailing Address - State:WI
Mailing Address - Zip Code:53562-5531
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:600 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:WI
Practice Address - Zip Code:53792-5204
Practice Address - Country:US
Practice Address - Phone:608-263-0946
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2024-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI83394-20207RI0200X
NY229632207R00000X, 207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
31967773OtherCIGNA HEALTH CARE
NWH TAX IDOtherDEVON HEALTH GRP PIN#
NWH TAX IDOtherCHN SOLUTIONS -GRP PIN #
0140665OtherGHI PPO PROVIDER ID
NWH TAX IDOtherPHCS-PROVIDER ID
10119993-U104OtherCDPHP PROVIDER # &GRP #
450AP1OtherEMPIRE BC-BS
7988846OtherAETNA PROVIDER ID PPO
000000114410OtherGHI - HMO
07020900104OtherFIDELIS CARE OF NY
1423323OtherAETNA HMO
396943OtherMVP HEALTHPLAN
NWH TAX IDOtherBEECH STREET PROVIDER ID
NWH TAX IDOtherPOMCO PROVIDER #
P003676971OtherRAILROAD MEDICARE PIN#
I66523Medicare UPIN
7988846OtherAETNA PROVIDER ID PPO