Provider Demographics
NPI:1619914348
Name:NAGOURNEY, LEE CRAIG (MD)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:CRAIG
Last Name:NAGOURNEY
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 1:315 E 105TH ST
Mailing Address - Street 2:SUITE 104B
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10029-5000
Mailing Address - Country:US
Mailing Address - Phone:646-454-1982
Mailing Address - Fax:646-476-3145
Practice Address - Street 1:315 E 105TH ST
Practice Address - Street 2:SUITE 104B
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10029-5000
Practice Address - Country:US
Practice Address - Phone:646-454-1982
Practice Address - Fax:646-476-3145
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-01
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY156199207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYF75478Medicare UPIN
NY65I331Medicare ID - Type Unspecified