Provider Demographics
NPI:1104959071
Name:MIMI LEE M.D., P.A.
Entity type:Organization
Organization Name:MIMI LEE M.D., P.A.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:MOYUEN
Authorized Official - Middle Name:MIMI
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:501-224-0880
Mailing Address - Street 1:8315 CANTRELL RD
Mailing Address - Street 2:PLAZA 80
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72227-2423
Mailing Address - Country:US
Mailing Address - Phone:501-224-0880
Mailing Address - Fax:501-224-1395
Practice Address - Street 1:8315 CANTRELL RD
Practice Address - Street 2:PLAZA 80
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72227-2423
Practice Address - Country:US
Practice Address - Phone:501-224-0880
Practice Address - Fax:501-224-1395
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-13
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARMC 2255208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208600000XAllopathic & Osteopathic PhysiciansSurgeryGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR5F979Medicare PIN