Basic Information
| Provider Information | |||||||||
| NPI: | 1801925565 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | CAROL | ||||||||
| MiddleName: | FROST | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 223 CIBECUE CIRCLE RD | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284757219 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 223 CIBECUE CIRCLE RD | ||||||||
| Address2: | |||||||||
| City: | SAN CARLOS | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 855500208 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9284757219 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/05/2007 | ||||||||
| LastUpdateDate: | 03/13/2015 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12002MD | OR | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 287780 | 05 | OR | MEDICAID |