Provider Demographics
NPI:1619105517
Name:LEE, TIDA KUMBALASIRI (MD, PHD)
Entity Type:Individual
Prefix:DR
First Name:TIDA
Middle Name:KUMBALASIRI
Last Name:LEE
Suffix:
Gender:F
Credentials:MD, PHD
Other - Prefix:
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Other - Middle Name:
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Mailing Address - Street 1:1202 MEDICAL CENTER DR
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28401-7307
Mailing Address - Country:US
Mailing Address - Phone:910-617-6705
Mailing Address - Fax:910-431-4048
Practice Address - Street 1:1000 BRABHAM AVE
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546-5003
Practice Address - Country:US
Practice Address - Phone:910-937-2570
Practice Address - Fax:910-219-1270
Is Sole Proprietor?:No
Enumeration Date:2009-06-30
Last Update Date:2022-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101248380207RI0200X
NC2022-02736207RI0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious Disease