Provider Demographics
NPI:1497713317
Name:LEE, DORINDA (MD)
Entity Type:Individual
Prefix:DR
First Name:DORINDA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DORINDA
Other - Middle Name:L
Other - Last Name:FAULKNER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2828 N NATIONAL AVE
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65803-4306
Mailing Address - Country:US
Mailing Address - Phone:417-837-4000
Mailing Address - Fax:417-875-4710
Practice Address - Street 1:2828 N NATIONAL AVE
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:MO
Practice Address - Zip Code:65803-4306
Practice Address - Country:US
Practice Address - Phone:417-837-4000
Practice Address - Fax:417-875-4710
Is Sole Proprietor?:No
Enumeration Date:2006-05-02
Last Update Date:2013-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2000153635207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO547630805Medicaid
P00786274OtherRR MEDICARE
MO1497713317Medicaid
MO263471Medicare ID - Type Unspecified
MO1497713317Medicaid
MO547630805Medicaid