Provider Demographics
NPI:1942405501
Name:LEE K GOLD DPM PC
Entity Type:Organization
Organization Name:LEE K GOLD DPM PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:KEVIN
Authorized Official - Last Name:GOLD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-227-4155
Mailing Address - Street 1:5889 WHITMORE LAKE RD
Mailing Address - Street 2:SUITE 1
Mailing Address - City:BRIGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:48116-1998
Mailing Address - Country:US
Mailing Address - Phone:810-227-4155
Mailing Address - Fax:810-227-0845
Practice Address - Street 1:5889 WHITMORE LAKE RD STE A
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1998
Practice Address - Country:US
Practice Address - Phone:810-227-4155
Practice Address - Fax:810-227-0845
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-15
Last Update Date:2019-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILG400121213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle SurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI480D710370OtherBLUE CROSS BLUE SHIELD