Provider Demographics
NPI:1457382475
Name:MUSKOVITZ, LEE ALAN
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ALAN
Last Name:MUSKOVITZ
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 1:400 E 3RD ST
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55805-1951
Mailing Address - Country:US
Mailing Address - Phone:218-786-3814
Mailing Address - Fax:
Practice Address - Street 1:13060 ISLE DRIVE
Practice Address - Street 2:
Practice Address - City:BAXTER
Practice Address - State:MN
Practice Address - Zip Code:56425
Practice Address - Country:US
Practice Address - Phone:218-828-2880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2018-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN396712080N0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080N0001XAllopathic & Osteopathic PhysiciansPediatricsNeonatal-Perinatal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32328900Medicaid
MN665320100Medicaid
MN665320100Medicaid
MN370001425Medicare ID - Type Unspecified