Provider Demographics
NPI:1770649675
Name:LEE, BRIAN M (MD)
Entity Type:Individual
Prefix:DR
First Name:BRIAN
Middle Name:M
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 34307
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-4307
Mailing Address - Country:US
Mailing Address - Phone:850-492-2010
Mailing Address - Fax:850-492-2012
Practice Address - Street 1:10 DOUG FORD DRIVE
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507
Practice Address - Country:US
Practice Address - Phone:850-492-2010
Practice Address - Fax:850-492-2012
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-28
Last Update Date:2014-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 79663207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
BC 49848OtherBLUE CROSS
FL5811648OtherAETNA
BC 49848OtherBLUE CROSS
49848AMedicare ID - Type Unspecified