Provider Demographics
NPI:1831152552
Name:JIMMERSON LEE, CAROLYN (DO)
Entity type:Individual
Prefix:DR
First Name:CAROLYN
Middle Name:
Last Name:JIMMERSON LEE
Suffix:
Gender:F
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:PO BOX 7042
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-7042
Mailing Address - Country:US
Mailing Address - Phone:248-910-6222
Mailing Address - Fax:
Practice Address - Street 1:22100 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-2550
Practice Address - Country:US
Practice Address - Phone:248-910-6222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-12
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICJ007802207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIE25607Medicare UPIN
MI0N35740Medicare ID - Type UnspecifiedMEDICARE