Provider Demographics
NPI:1720182132
Name:LEE, CHANG SU (DO)
Entity type:Individual
Prefix:
First Name:CHANG
Middle Name:SU
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 815
Mailing Address - Street 2:169 MARTIN AVENUE
Mailing Address - City:EPHRATA
Mailing Address - State:PA
Mailing Address - Zip Code:17522
Mailing Address - Country:US
Mailing Address - Phone:717-859-4533
Mailing Address - Fax:717-859-4475
Practice Address - Street 1:169 MARTIN AVENUE
Practice Address - Street 2:
Practice Address - City:EPHRATA
Practice Address - State:PA
Practice Address - Zip Code:17522
Practice Address - Country:US
Practice Address - Phone:717-859-4533
Practice Address - Fax:717-859-4475
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOS012276207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology