Basic Information
| Provider Information | |||||||||
| NPI: | 1083641849 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | DAVID | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LEE | ||||||||
| OtherFirstName: | CHANG | ||||||||
| OtherMiddleName: | |||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 623 | ||||||||
| Address2: | |||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467060623 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609278105 | ||||||||
| FaxNumber: | 2609278026 | ||||||||
| Practice Location | |||||||||
| Address1: | 1314 E 7TH ST | ||||||||
| Address2: | SUITE 203 | ||||||||
| City: | AUBURN | ||||||||
| State: | IN | ||||||||
| PostalCode: | 467062535 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2609278105 | ||||||||
| FaxNumber: | 2609278026 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2006 | ||||||||
| LastUpdateDate: | 08/29/2013 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | 36-048308 | IL | N | Other Service Providers | Specialist | 207Y00000X | 01039322A | IN | Y | Allopathic & Osteopathic Physicians | Otolaryngology |
ID Information
| ID | Type | State | Issuer | Description | 216-07247 | 01 | IL | BCBS | OTHER | 036048308 | 05 | IL | MEDICAID |