Provider Demographics
NPI:1578511911
Name:LEE, DAVID ETHAN (MD)
Entity Type:Individual
Prefix:DR
First Name:DAVID
Middle Name:ETHAN
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
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Mailing Address - Street 1:PO BOX 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-712-0700
Mailing Address - Fax:336-712-0876
Practice Address - Street 1:7130 VILLAGE MEDICAL CIR
Practice Address - Street 2:
Practice Address - City:CLEMMONS
Practice Address - State:NC
Practice Address - Zip Code:27012-8004
Practice Address - Country:US
Practice Address - Phone:336-893-2420
Practice Address - Fax:336-893-2431
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC2006-00237207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5904219Medicaid
NC5904219Medicaid