Provider Demographics
NPI:1265463517
Name:LEE, EDWARD ALLEN (MD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:ALLEN
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 712
Mailing Address - Street 2:
Mailing Address - City:EDMOND
Mailing Address - State:OK
Mailing Address - Zip Code:73083-0712
Mailing Address - Country:US
Mailing Address - Phone:405-527-2194
Mailing Address - Fax:405-527-2195
Practice Address - Street 1:1401 N 4TH AVE
Practice Address - Street 2:SUITE 101
Practice Address - City:PURCELL
Practice Address - State:OK
Practice Address - Zip Code:73080-1806
Practice Address - Country:US
Practice Address - Phone:405-527-2194
Practice Address - Fax:405-527-2195
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-05
Last Update Date:2013-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK15079207Q00000X
OK11807207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR826013719OtherRAILROAD MCARE
OK100099310AMedicaid
PR826013719OtherRAILROAD MCARE
OKD34931Medicare UPIN