Provider Demographics
NPI:1083612550
Name:LEE, SALVADOR T JR (MD)
Entity type:Individual
Prefix:
First Name:SALVADOR
Middle Name:T
Last Name:LEE
Suffix:JR
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 1:102 E THIRD ST
Mailing Address - Street 2:
Mailing Address - City:WINSLOW
Mailing Address - State:AZ
Mailing Address - Zip Code:86047-3743
Mailing Address - Country:US
Mailing Address - Phone:928-289-3345
Mailing Address - Fax:928-289-3760
Practice Address - Street 1:102 E THIRD ST
Practice Address - Street 2:
Practice Address - City:WINSLOW
Practice Address - State:AZ
Practice Address - Zip Code:86047-3743
Practice Address - Country:US
Practice Address - Phone:928-289-3345
Practice Address - Fax:928-289-3760
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-08
Last Update Date:2007-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ13771207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ228024Medicaid
AZ228024Medicaid