Provider Demographics
NPI:1821040155
Name:LEE, MICHAEL D (DO)
Entity Type:Individual
Prefix:
First Name:MICHAEL
Middle Name:D
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 1:202 DUKE OF GLOUCESTER ST SW
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24014-1372
Mailing Address - Country:US
Mailing Address - Phone:540-345-4900
Mailing Address - Fax:540-345-4179
Practice Address - Street 1:202 DUKE OF GLOUCESTER ST SW
Practice Address - Street 2:
Practice Address - City:ROANOKE
Practice Address - State:VA
Practice Address - Zip Code:24014-1372
Practice Address - Country:US
Practice Address - Phone:540-345-4900
Practice Address - Fax:540-345-4179
Is Sole Proprietor?:No
Enumeration Date:2006-05-16
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC519207RG0100X
VA0102049900207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1821040155Medicaid
SCT00390Medicaid
VA014545G79Medicare PIN
VA1821040155Medicaid
SCF815734759Medicare ID - Type Unspecified