Provider Demographics
NPI:1821143538
Name:LEE, CHARLES CHURLMIN (MD)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:CHURLMIN
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 639
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20725
Mailing Address - Country:US
Mailing Address - Phone:301-317-0020
Mailing Address - Fax:301-317-0028
Practice Address - Street 1:1711 LIVINGSTON RD
Practice Address - Street 2:
Practice Address - City:FORT MEADE
Practice Address - State:MD
Practice Address - Zip Code:20744
Practice Address - Country:US
Practice Address - Phone:301-317-0020
Practice Address - Fax:301-317-0028
Is Sole Proprietor?:No
Enumeration Date:2007-01-24
Last Update Date:2013-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0053060207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
F86285Medicare UPIN
DC014723F55Medicare ID - Type UnspecifiedTRAIL BLAZER