Provider Demographics
NPI:1417974072
Name:PERIOLAT, LEE M (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:M
Last Name:PERIOLAT
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 1:601 WALL ST
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2512
Mailing Address - Country:US
Mailing Address - Phone:219-531-3662
Mailing Address - Fax:
Practice Address - Street 1:601 WALL ST
Practice Address - Street 2:
Practice Address - City:VALPARAISO
Practice Address - State:IN
Practice Address - Zip Code:46383-2512
Practice Address - Country:US
Practice Address - Phone:219-531-3662
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-17
Last Update Date:2020-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN010264842084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry