Provider Demographics
NPI:1588633630
Name:LEE, KENYATTA Y (MD)
Entity Type:Individual
Prefix:DR
First Name:KENYATTA
Middle Name:Y
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 1:7703 FLOYD CURL DR # MC7977
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3901
Mailing Address - Country:US
Mailing Address - Phone:210-358-3985
Mailing Address - Fax:
Practice Address - Street 1:903 W MARTIN ST
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78207-0903
Practice Address - Country:US
Practice Address - Phone:210-358-5942
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-14
Last Update Date:2018-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXR3548207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA312995964AMedicaid
TX377442401Medicaid
FL2701022-00Medicaid
FL270102200Medicaid
FLP00191364OtherRAILROAD MEDICARE
GA312995964AMedicaid