Basic Information
| Provider Information | |||||||||
| NPI: | 1316966971 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | ALBERT | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 846098 | ||||||||
| Address2: | |||||||||
| City: | DALLAS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 752846098 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9033246450 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 520 E DOUGLAS BLVD | ||||||||
| Address2: | |||||||||
| City: | TYLER | ||||||||
| State: | TX | ||||||||
| PostalCode: | 757028307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9035931721 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/18/2006 | ||||||||
| LastUpdateDate: | 01/04/2016 | ||||||||
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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 | G58417 | CA | N | Other Service Providers | Specialist | 2085R0202X | N0916 | TX | Y | Allopathic & Osteopathic Physicians | Radiology | Diagnostic Radiology |
ID Information
| ID | Type | State | Issuer | Description | 196640002 | 05 | TX | MEDICAID | 8CU212 | 01 | TX | BCBS JV LOCATION | OTHER | 196640001 | 05 | TX | MEDICAID | 196640003 | 05 | TX | MEDICAID | TIN PLUS 113 | 01 | TX | TRICARE | OTHER | 196640004 | 05 | TX | MEDICAID | TIN PLUS 013 | 01 | TX | TRICARE | OTHER | 8BC077 | 01 | TX | BCBS OF TEXAS | OTHER | 8AP484 | 01 | TX | BCBS | OTHER | TIN PLUS 005 | 01 | TX | TRICARE JV LOCATION | OTHER | TIN PLUS 007 | 01 | TX | TRICARE | OTHER |