Provider Demographics
NPI:1972747749
Name:LEE, SONG EUN (MD)
Entity type:Individual
Prefix:
First Name:SONG EUN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:1200 E RIDGEWOOD AVE
Mailing Address - Street 2:STE #207
Mailing Address - City:RIDGEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:07450-3952
Mailing Address - Country:US
Mailing Address - Phone:201-612-9600
Mailing Address - Fax:201-612-0428
Practice Address - Street 1:1200 E RIDGEWOOD AVE
Practice Address - Street 2:STE #207
Practice Address - City:RIDGEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07450-3952
Practice Address - Country:US
Practice Address - Phone:201-612-9600
Practice Address - Fax:201-612-0428
Is Sole Proprietor?:No
Enumeration Date:2009-04-23
Last Update Date:2015-09-10
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25MA09694900207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology