Provider Demographics
NPI:1659805521
Name:LEE, MALCOLM MANDELA I (MD, CLS)
Entity Type:Individual
Prefix:DR
First Name:MALCOLM
Middle Name:MANDELA
Last Name:LEE
Suffix:I
Gender:M
Credentials:MD, CLS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:344 VICTORY DR
Mailing Address - Street 2:
Mailing Address - City:PARK FOREST
Mailing Address - State:IL
Mailing Address - Zip Code:60466-2003
Mailing Address - Country:US
Mailing Address - Phone:708-490-3340
Mailing Address - Fax:
Practice Address - Street 1:344 VICTORY DR
Practice Address - Street 2:
Practice Address - City:PARK FOREST
Practice Address - State:IL
Practice Address - Zip Code:60466-2003
Practice Address - Country:US
Practice Address - Phone:708-490-3340
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2024-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL1744R1102X
IL16598055212085U0001X
246QM0706X
IL10847788291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes291U00000XLaboratoriesClinical Medical Laboratory
Yes1744R1102XOther Service ProvidersSpecialistResearch StudyGroup - Single Specialty
No2085U0001XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic UltrasoundGroup - Single Specialty
No246QM0706XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, PathologyMedical TechnologistGroup - Single Specialty