Provider Demographics
NPI:1689768061
Name:LEE, DERRICK O (MD)
Entity Type:Individual
Prefix:
First Name:DERRICK
Middle Name:O
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 26666
Mailing Address - Street 2:PHS PROVIDER ENROLLMENT
Mailing Address - City:ALBUQUERQUE
Mailing Address - State:NM
Mailing Address - Zip Code:87125-6666
Mailing Address - Country:US
Mailing Address - Phone:505-923-5356
Mailing Address - Fax:505-923-5354
Practice Address - Street 1:PMG HOSPITALISTS
Practice Address - Street 2:1100 CENTRAL SE 4TH FLOOR
Practice Address - City:ALBUQUERQUE
Practice Address - State:NM
Practice Address - Zip Code:87106
Practice Address - Country:US
Practice Address - Phone:505-724-6124
Practice Address - Fax:505-724-6125
Is Sole Proprietor?:No
Enumeration Date:2006-10-03
Last Update Date:2022-02-04
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Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NMMD2004-0036207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NM59272252Medicaid
NM59272252Medicaid
341426409Medicare PIN