Provider Demographics
NPI:1275502882
Name:LEE, PETER (DO)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
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 620
Mailing Address - Street 2:
Mailing Address - City:LIBERAL
Mailing Address - State:KS
Mailing Address - Zip Code:67905-0620
Mailing Address - Country:US
Mailing Address - Phone:620-624-7070
Mailing Address - Fax:620-624-7757
Practice Address - Street 1:23 E 11TH ST
Practice Address - Street 2:
Practice Address - City:LIBERAL
Practice Address - State:KS
Practice Address - Zip Code:67901-2720
Practice Address - Country:US
Practice Address - Phone:620-624-7070
Practice Address - Fax:620-624-7757
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS05-22558207Q00000X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Not Answered208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS102900OtherBCBS OF KANSAS
KSX89482Medicare UPIN
KS102900Medicare ID - Type Unspecified