Provider Demographics
NPI:1841259348
Name:LEE, KEN W (MD)
Entity type:Individual
Prefix:DR
First Name:KEN
Middle Name:W
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3300 S FISKE BLVD
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-4306
Mailing Address - Country:US
Mailing Address - Phone:321-434-9568
Mailing Address - Fax:
Practice Address - Street 1:8725 N WICKHAM RD
Practice Address - Street 2:
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32940-2239
Practice Address - Country:US
Practice Address - Phone:321-434-9568
Practice Address - Fax:321-434-9231
Is Sole Proprietor?:No
Enumeration Date:2006-03-22
Last Update Date:2025-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME133936207RC0001X, 207RC0001X
OH35.092772207RC0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0001XAllopathic & Osteopathic PhysiciansInternal MedicineClinical Cardiac Electrophysiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL022559000Medicaid
FLJD812ZOtherMEDICARE
FLJD812ZOtherMEDICARE
H26489Medicare UPIN
OHH306730Medicare PIN