Provider Demographics
NPI:1639484116
Name:LEE, ILDE MANUEL
Entity Type:Individual
Prefix:
First Name:ILDE
Middle Name:MANUEL
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:110 BARD AVE APT 4
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-3205
Mailing Address - Country:US
Mailing Address - Phone:903-440-0013
Mailing Address - Fax:
Practice Address - Street 1:110 BARD AVE APT 4
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310-3205
Practice Address - Country:US
Practice Address - Phone:903-440-0013
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-08-09
Last Update Date:2012-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NY265685207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program