Provider Demographics
NPI:1740578483
Name:LEE, IAN C (MD)
Entity Type:Individual
Prefix:
First Name:IAN
Middle Name:C
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:PO BOX 751069
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1069
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:234 CROOKED CREEK PKWY STE 420
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27713
Practice Address - Country:US
Practice Address - Phone:919-668-7600
Practice Address - Fax:919-385-7536
Is Sole Proprietor?:Yes
Enumeration Date:2011-07-15
Last Update Date:2018-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-005382084N0400X
PAMD4583952084N0400X
NY2666382084N0400X
PAMT199936390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC19LT8OtherBCBS OF NC
NC1740578483Medicaid
NC19LT8OtherBCBS OF NC