Basic Information
| Provider Information | |||||||||
| NPI: | 1326006479 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | WILFRED | ||||||||
| MiddleName: | KWONG | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12550 PROFESSIONAL PARK DRIVE | ||||||||
| Address2: | SUITE 11 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397682111 | ||||||||
| FaxNumber: | 2394824404 | ||||||||
| Practice Location | |||||||||
| Address1: | 13650 METROPOLIS AVENUE | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | FORT MYERS | ||||||||
| State: | FL | ||||||||
| PostalCode: | 33912 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2397682111 | ||||||||
| FaxNumber: | 2397682113 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/01/2006 | ||||||||
| LastUpdateDate: | 08/14/2013 | ||||||||
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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 | 208000000X | ME71067 | FL | Y | Allopathic & Osteopathic Physicians | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 250532100 | 05 | FL | MEDICAID |