Provider Demographics
NPI:1083619779
Name:LEE, CARLO C (MD)
Entity Type:Individual
Prefix:
First Name:CARLO
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2426
Mailing Address - Street 2:
Mailing Address - City:WARNER ROBINS
Mailing Address - State:GA
Mailing Address - Zip Code:31099-2426
Mailing Address - Country:US
Mailing Address - Phone:478-923-6462
Mailing Address - Fax:478-923-6215
Practice Address - Street 1:1570 WATSON BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:WARNER ROBINS
Practice Address - State:GA
Practice Address - Zip Code:31093-3432
Practice Address - Country:US
Practice Address - Phone:478-923-6462
Practice Address - Fax:478-923-6215
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-17
Last Update Date:2011-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA041455207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000725029JMedicaid
GA000725029EMedicaid
GA000725029IMedicaid
GA000725029IMedicaid
GA202G703838Medicare PIN
GA511I160033Medicare PIN
GA16BDSLGMedicare ID - Type Unspecified
GA000725029JMedicaid