Provider Demographics
NPI:1689809345
Name:LEE, CRYSTAL RENEE (MD)
Entity Type:Individual
Prefix:DR
First Name:CRYSTAL
Middle Name:RENEE
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:CRYSTAL
Other - Middle Name:RENEE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:18859 RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48203-2115
Mailing Address - Country:US
Mailing Address - Phone:313-207-4708
Mailing Address - Fax:
Practice Address - Street 1:97 MONROE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2855
Practice Address - Country:US
Practice Address - Phone:313-965-3365
Practice Address - Fax:313-965-3622
Is Sole Proprietor?:Yes
Enumeration Date:2009-05-26
Last Update Date:2022-12-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY296676207R00000X
CAC159427207R00000X
TXS0496207R00000X
MI4301094933207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine