Provider Demographics
NPI:1891796421
Name:LEE, DAVID
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1701 12TH AVE
Mailing Address - Street 2:BUILDING A
Mailing Address - City:ALTOONA
Mailing Address - State:PA
Mailing Address - Zip Code:16601-3100
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1701 12TH AVE
Practice Address - Street 2:BUILDING A
Practice Address - City:ALTOONA
Practice Address - State:PA
Practice Address - Zip Code:16601-3100
Practice Address - Country:US
Practice Address - Phone:814-944-7097
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-04
Last Update Date:2021-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD040528E207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0011414890005Medicaid
PA0011414890005Medicaid
PAC30329Medicare UPIN