Basic Information
Provider Information | |||||||||
NPI: | 1164699963 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | LEE | ||||||||
FirstName: | SUN | ||||||||
MiddleName: | Y | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | M.D. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | LEE-MARQUEZ | ||||||||
OtherFirstName: | SUN | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: | 5 | ||||||||
Mailing Information | |||||||||
Address1: | 801 ALBANY ST | ||||||||
Address2: | FL G | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 02119 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: |   | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 732 HARRISON AVE | ||||||||
Address2: | PRESTON FAMILY BUILDING 2ND FLOOR | ||||||||
City: | BOSTON | ||||||||
State: | MA | ||||||||
PostalCode: | 021182309 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6176387470 | ||||||||
FaxNumber: | 6176387449 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/12/2008 | ||||||||
LastUpdateDate: | 04/28/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 04/28/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 245270 | MA | N |   | Allopathic & Osteopathic Physicians | Internal Medicine |   | 207RE0101X | 245270 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine | Endocrinology, Diabetes & Metabolism |
ID Information
ID | Type | State | Issuer | Description | 110086228A | 05 | MA |   | MEDICAID | 3120299 | 05 | NH |   | MEDICAID |