Provider Demographics
NPI:1669566303
Name:EDSTROM, LEE EVERETT (MD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:EVERETT
Last Name:EDSTROM
Suffix:
Gender:M
Credentials:MD
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Mailing Address - Street 1:2 DUDLEY
Mailing Address - Street 2:SUITE 460
Mailing Address - City:PROVIDENCE
Mailing Address - State:RI
Mailing Address - Zip Code:02905
Mailing Address - Country:US
Mailing Address - Phone:401-331-2303
Mailing Address - Fax:401-331-4430
Practice Address - Street 1:2 DUDLEY
Practice Address - Street 2:SUITE 460
Practice Address - City:PROVIDENCE
Practice Address - State:RI
Practice Address - Zip Code:02905
Practice Address - Country:US
Practice Address - Phone:401-331-2303
Practice Address - Fax:401-331-4430
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
RI5949208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI1300121OtherUNITED HEALTH
RI300043OtherBLUECHIP
RI050395339OtherTAX ID
RI050395339OtherTAX ID
RIRI5949OtherDEA#