Provider Demographics
NPI:1770508376
Name:LEE, SAMUEL C (DO)
Entity type:Individual
Prefix:
First Name:SAMUEL
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1412 MAY ST
Mailing Address - Street 2:
Mailing Address - City:FORT WORTH
Mailing Address - State:TX
Mailing Address - Zip Code:76104-7639
Mailing Address - Country:US
Mailing Address - Phone:817-625-8818
Mailing Address - Fax:817-625-7850
Practice Address - Street 1:1412 MAY ST
Practice Address - Street 2:
Practice Address - City:FORT WORTH
Practice Address - State:TX
Practice Address - Zip Code:76104-7639
Practice Address - Country:US
Practice Address - Phone:817-625-8818
Practice Address - Fax:817-625-7850
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK0107207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX102016603Medicaid
TX102016603Medicaid