Basic Information
Provider Information
NPI: 1457340671
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEE
FirstName: SUO
MiddleName: YI
NamePrefix: DR.
NameSuffix:  
Credential: MD
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2100 DORCHESTER AVE
Address2: SUITE 311
City: DORCHESTER CENTER
State: MA
PostalCode: 021245615
CountryCode: US
TelephoneNumber: 6172960456
FaxNumber:  
Practice Location
Address1: 2100 DORCHESTER AVE
Address2: SUITE 311
City: QUINCY
State: MA
PostalCode: 021690909
CountryCode: US
TelephoneNumber: 6172960456
FaxNumber:  
Other Information
ProviderEnumerationDate: 10/20/2005
LastUpdateDate: 11/17/2011
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
207R00000X203541MAY Allopathic & Osteopathic PhysiciansInternal Medicine 

ID Information
IDTypeStateIssuerDescription
237535401 AETNA/US HEALTHCAREOTHER
21059010401 UNITED HEALTHCARE OF NEOTHER
00000002020801MABOSTON HEALTH NETOTHER
010372105MA MEDICAID
6983601MAHARVARD PILGRIM HEALTH CAOTHER
20354101 TUFTS ASSOCIATED HEALTH POTHER
002443901MANEIGHBORHOOD HEALTH PLANOTHER
J2261101 BLUE CROSS/BLUE SHIELDOTHER
B1047620101 CIGNA HEALTHCAREOTHER


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