Provider Demographics
NPI:1699853390
Name:LEE, GARY G (DO)
Entity Type:Individual
Prefix:DR
First Name:GARY
Middle Name:G
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:304 FRANKLIN ST
Mailing Address - Street 2:
Mailing Address - City:KEOSAUQUA
Mailing Address - State:IA
Mailing Address - Zip Code:52565-1164
Mailing Address - Country:US
Mailing Address - Phone:319-293-3171
Mailing Address - Fax:
Practice Address - Street 1:304 FRANKLIN ST
Practice Address - Street 2:
Practice Address - City:KEOSAUQUA
Practice Address - State:IA
Practice Address - Zip Code:52565-1164
Practice Address - Country:US
Practice Address - Phone:319-293-3171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-01
Last Update Date:2009-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOR8333207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO241540301Medicaid
MO43-1338234OtherTAX ID
MO000002580Medicare ID - Type Unspecified
MOD41487Medicare UPIN