Provider Demographics
NPI:1376732628
Name:LEE, TRAVIS (MD)
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
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 1:2147 OLD GREENBRIER RD
Mailing Address - Street 2:SUITE B
Mailing Address - City:CHESAPEAKE
Mailing Address - State:VA
Mailing Address - Zip Code:23320-2635
Mailing Address - Country:US
Mailing Address - Phone:757-366-0200
Mailing Address - Fax:949-225-1619
Practice Address - Street 1:2147 OLD GREENBRIER RD
Practice Address - Street 2:SUITE B
Practice Address - City:CHESAPEAKE
Practice Address - State:VA
Practice Address - Zip Code:23320-2635
Practice Address - Country:US
Practice Address - Phone:757-366-0200
Practice Address - Fax:949-225-1619
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-22
Last Update Date:2016-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA01012413012081S0010X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No2081S0010XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationSports Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
VAC10410Medicare PIN