1083641849 NPI number — DAVID C LEE MD

Table of content: DAVID C LEE MD (NPI 1083641849)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083641849 NPI number — DAVID C LEE MD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
DAVID
Provider Middle Name:
C
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
MD
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
CHANG
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
MD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083641849
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 623
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
AUBURN
Provider Business Mailing Address State Name:
IN
Provider Business Mailing Address Postal Code:
46706-0623
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
260-927-8105
Provider Business Mailing Address Fax Number:
260-927-8026

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1314 E 7TH ST
Provider Second Line Business Practice Location Address:
SUITE 203
Provider Business Practice Location Address City Name:
AUBURN
Provider Business Practice Location Address State Name:
IN
Provider Business Practice Location Address Postal Code:
46706-2535
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
260-927-8105
Provider Business Practice Location Address Fax Number:
260-927-8026
Provider Enumeration Date:
06/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 174400000X , with the licence number:  36-048308 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207Y00000X , with the licence number: 01039322A , registered in the state of IN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 216-07247 . This is a "BCBS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".
  • Identifier: 036048308 , issued by the state of ( IL ) . This identifiers is of the category "MEDICAID".




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