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
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 203541 | MA | Y |   | Allopathic & Osteopathic Physicians | Internal Medicine |   |
ID Information
ID | Type | State | Issuer | Description | 2375354 | 01 |   | AETNA/US HEALTHCARE | OTHER | 210590104 | 01 |   | UNITED HEALTHCARE OF NE | OTHER | 000000020208 | 01 | MA | BOSTON HEALTH NET | OTHER | 0103721 | 05 | MA |   | MEDICAID | 69836 | 01 | MA | HARVARD PILGRIM HEALTH CA | OTHER | 203541 | 01 |   | TUFTS ASSOCIATED HEALTH P | OTHER | 0024439 | 01 | MA | NEIGHBORHOOD HEALTH PLAN | OTHER | J22611 | 01 |   | BLUE CROSS/BLUE SHIELD | OTHER | B10476201 | 01 |   | CIGNA HEALTHCARE | OTHER |