Provider Demographics
NPI:1508867656
Name:LEE, BRIAN J (MD)
Entity Type:Individual
Prefix:
First Name:BRIAN
Middle Name:J
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 1:7910 W JEFFERSON BLVD STE 212
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46804-4159
Mailing Address - Country:US
Mailing Address - Phone:260-427-7473
Mailing Address - Fax:260-432-3189
Practice Address - Street 1:7910 W JEFFERSON BLVD STE 212
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46804-4159
Practice Address - Country:US
Practice Address - Phone:260-427-7473
Practice Address - Fax:260-432-3189
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01040298A208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0984010Medicaid
IN100372020Medicaid
IN240007525OtherMEDICARE RAILROAD
MI104366796Medicaid
OH0984010Medicaid
IN240007525OtherMEDICARE RAILROAD
IN186080AMedicare PIN