Provider Demographics
NPI:1689606881
Name:LEE, THEODORE MARK (MD)
Entity Type:Individual
Prefix:
First Name:THEODORE
Middle Name:MARK
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 1:1800 PEACHTREE ST. NW
Mailing Address - Street 2:SUITE 720
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30309-2511
Mailing Address - Country:US
Mailing Address - Phone:404-351-7520
Mailing Address - Fax:404-355-2048
Practice Address - Street 1:1800 PEACHTREE ST. NW
Practice Address - Street 2:SUITE 720
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30309-2511
Practice Address - Country:US
Practice Address - Phone:404-351-7520
Practice Address - Fax:404-355-2048
Is Sole Proprietor?:No
Enumeration Date:2006-07-07
Last Update Date:2012-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA024014207KA0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207KA0200XAllopathic & Osteopathic PhysiciansAllergy & ImmunologyAllergy
Provider Identifiers
StateIdentifier IDID TypeIssuer
480827OtherBCBS
2754388008OtherCIGNA
GAP00162933OtherRAILROAD MEDICARE
GA00278649KOtherMEDICADE
8791OtherKAISER POS
GA00278649HMedicaid
0481981OtherAETNA
1950OtherCOVENTRY
GAP00162933OtherRAILROAD MEDICARE
GA00278649HMedicaid