Basic Information
| Provider Information | |||||||||
| NPI: | 1699756189 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MICHAEL | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DPM | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1061 HARMON AVE | ||||||||
| Address2: | STE 1D03 | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313145641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124355965 | ||||||||
| FaxNumber: | 9124355965 | ||||||||
| Practice Location | |||||||||
| Address1: | 1061 HARMON AVE | ||||||||
| Address2: | STE 1D03 | ||||||||
| City: | FORT STEWART | ||||||||
| State: | GA | ||||||||
| PostalCode: | 313145641 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9124355965 | ||||||||
| FaxNumber: | 9124355965 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/10/2005 | ||||||||
| LastUpdateDate: | 06/01/2016 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 213E00000X | PO00000732 | WA | Y | Podiatric Medicine & Surgery Service Providers | Podiatrist |
ID Information
| ID | Type | State | Issuer | Description | 8377848 | 05 | WA | MEDICAID |