Provider Demographics
NPI:1306925136
Name:GOLD, LEE KEVIN (DPM)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:KEVIN
Last Name:GOLD
Suffix:
Gender:M
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6647 BRISTOL DR
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48322-3263
Mailing Address - Country:US
Mailing Address - Phone:248-661-1974
Mailing Address - Fax:
Practice Address - Street 1:5889 WHITMORE LAKE RD
Practice Address - Street 2:SUITE 1
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-1998
Practice Address - Country:US
Practice Address - Phone:810-227-4155
Practice Address - Fax:810-227-0845
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-03
Last Update Date:2012-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MILG400121213ES0103X
MI5401400121213EP1101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No213EP1101XPodiatric Medicine & Surgery Service ProvidersPodiatristPrimary Podiatric Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3113590Medicaid
MI4894750020OtherBCBS NUMBER
MI9475002Medicare ID - Type UnspecifiedMEDICARE NUMBER
MIT34302Medicare UPIN