Provider Demographics
NPI:1083641849
Name:LEE, DAVID C (MD)
Entity type:Individual
Prefix:
First Name:DAVID
Middle Name:C
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:CHANG
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 623
Mailing Address - Street 2:
Mailing Address - City:AUBURN
Mailing Address - State:IN
Mailing Address - Zip Code:46706-0623
Mailing Address - Country:US
Mailing Address - Phone:260-927-8105
Mailing Address - Fax:260-927-8026
Practice Address - Street 1:1314 E 7TH ST
Practice Address - Street 2:SUITE 203
Practice Address - City:AUBURN
Practice Address - State:IN
Practice Address - Zip Code:46706-2535
Practice Address - Country:US
Practice Address - Phone:260-927-8105
Practice Address - Fax:260-927-8026
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2013-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL36-048308174400000X
IN01039322A207Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Y00000XAllopathic & Osteopathic PhysiciansOtolaryngology
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL216-07247OtherBCBS
IL036048308Medicaid
IL036048308Medicaid