Basic Information
| Provider Information | |||||||||
| NPI: | 1861413536 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MARK | ||||||||
| MiddleName: | ROBERT | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 333 N SANTA ROSA | ||||||||
| Address2: | |||||||||
| City: | SAN ANTONIO | ||||||||
| State: | TX | ||||||||
| PostalCode: | 782073108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2107044100 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40 MEDICAL PARK STE 508 | ||||||||
| Address2: | |||||||||
| City: | WHEELING | ||||||||
| State: | WV | ||||||||
| PostalCode: | 26003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3042438916 | ||||||||
| FaxNumber: | 3042437194 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/21/2006 | ||||||||
| LastUpdateDate: | 02/09/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/09/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207T00000X | 28512 | WV | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 039151 | GA | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 207T00000X | 27496 | SC | N | Allopathic & Osteopathic Physicians | Neurological Surgery | 2086S0120X | N2167 | TX | N | Allopathic & Osteopathic Physicians | Surgery | Pediatric Surgery | 207T00000X | N2167 | TX | Y | Allopathic & Osteopathic Physicians | Neurological Surgery |
ID Information
| ID | Type | State | Issuer | Description | 000618032E | 05 | GA | MEDICAID | GRP8134 | 01 | GA | MEDICARE GROUP# | OTHER |