Provider Demographics
NPI:1093071870
Name:LEE, BRYAN S (MD)
Entity Type:Individual
Prefix:DR
First Name:BRYAN
Middle Name:S
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 1:2910 N 3RD AVE # 200
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85013-4434
Mailing Address - Country:US
Mailing Address - Phone:623-562-5050
Mailing Address - Fax:623-562-5051
Practice Address - Street 1:19636 N 27TH AVE STE 203
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85027-4022
Practice Address - Country:US
Practice Address - Phone:623-562-5050
Practice Address - Fax:623-562-5051
Is Sole Proprietor?:No
Enumeration Date:2012-04-06
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ57982207T00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ504576Medicaid