Provider Demographics
NPI:1366426397
Name:LEE, KENTON (MD)
Entity type:Individual
Prefix:DR
First Name:KENTON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1601 PARKVIEW AVE
Mailing Address - Street 2:CREDENTIALING S200C
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61107-1822
Mailing Address - Country:US
Mailing Address - Phone:815-395-5861
Mailing Address - Fax:815-395-5575
Practice Address - Street 1:3775 N MULFORD RD
Practice Address - Street 2:
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61114-5632
Practice Address - Country:US
Practice Address - Phone:779-696-9202
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-12-02
Last Update Date:2024-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036089913207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036089913Medicaid
IL036089913OtherSTATE LICENSE