Provider Demographics
NPI:1548227044
Name:ANTIGUA-LEE, MARCIA ELIZA (MD)
Entity Type:Individual
Prefix:MRS
First Name:MARCIA
Middle Name:ELIZA
Last Name:ANTIGUA-LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:12550 PROFESSIONAL PARK DRIVE
Mailing Address - Street 2:SUITE 11
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33913
Mailing Address - Country:US
Mailing Address - Phone:239-768-2111
Mailing Address - Fax:239-482-4404
Practice Address - Street 1:13650 METROPOLIS AVENUE
Practice Address - Street 2:SUITE 101
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33912
Practice Address - Country:US
Practice Address - Phone:239-768-2111
Practice Address - Fax:239-768-2113
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2013-08-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLME68892208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL379722800Medicaid
FLH70836Medicare UPIN
FL31604Medicare ID - Type Unspecified