Provider Demographics
NPI:1639121361
Name:SELF, LEE (MD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:SELF
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23000 SWEET OLA HWY
Mailing Address - Street 2:
Mailing Address - City:OLA
Mailing Address - State:ID
Mailing Address - Zip Code:83657-5027
Mailing Address - Country:US
Mailing Address - Phone:208-880-4904
Mailing Address - Fax:208-584-9341
Practice Address - Street 1:2020 S JOHNS AVE STE B
Practice Address - Street 2:
Practice Address - City:EMMETT
Practice Address - State:ID
Practice Address - Zip Code:83617-9410
Practice Address - Country:US
Practice Address - Phone:208-425-7507
Practice Address - Fax:208-541-9341
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-17
Last Update Date:2023-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM7844207V00000X, 207VX0000X, 207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID54742OtherBLUE CROSS
ID000010143995OtherBLUE SHIELD
ID1935544OtherCCN FIRST HEALTH NET
G54806Medicare UPIN
ID54742OtherBLUE CROSS