Provider Demographics
NPI:1902842941
Name:LEE, MATTHEW R (MD)
Entity Type:Individual
Prefix:
First Name:MATTHEW
Middle Name:R
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 717
Mailing Address - Street 2:
Mailing Address - City:MOUNT VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47620-0717
Mailing Address - Country:US
Mailing Address - Phone:812-838-4891
Mailing Address - Fax:812-838-6595
Practice Address - Street 1:1900 WEST FOURTH STREET
Practice Address - Street 2:SUITE 4
Practice Address - City:MOUNT VERNON
Practice Address - State:IN
Practice Address - Zip Code:47620
Practice Address - Country:US
Practice Address - Phone:812-838-4891
Practice Address - Fax:812-838-6595
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2010-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01032902207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000043063OtherBCBS
IN100210240AMedicaid
IN660640Medicare ID - Type Unspecified
IN000000043063OtherBCBS