Provider Demographics
NPI:1457378093
Name:LEE, CLIFTON C (MD)
Entity type:Individual
Prefix:
First Name:CLIFTON
Middle Name:C
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 91734
Mailing Address - Street 2:
Mailing Address - City:RICHMOND
Mailing Address - State:VA
Mailing Address - Zip Code:23291-1734
Mailing Address - Country:US
Mailing Address - Phone:804-358-6100
Mailing Address - Fax:804-342-7619
Practice Address - Street 1:1250 E MARSHALL STREET
Practice Address - Street 2:PEDIATRICS
Practice Address - City:RICHMOND
Practice Address - State:VA
Practice Address - Zip Code:23298-0510
Practice Address - Country:US
Practice Address - Phone:804-628-7337
Practice Address - Fax:804-828-6301
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2011-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101053632208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA006715591Medicaid
VA1457378093Medicaid
VA006715591Medicaid
VA370001115Medicare PIN
VA1457378093Medicaid
G60202Medicare UPIN