Provider Demographics
NPI:1386905099
Name:LEE, NATHANIEL A (MD)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:A
Last Name:LEE
Suffix:
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 1:2200 SANTA MONICA BLVD
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-2312
Mailing Address - Country:US
Mailing Address - Phone:310-449-5291
Mailing Address - Fax:310-582-7185
Practice Address - Street 1:8936 SOUTHPOINTE DR STE B4
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46227-7506
Practice Address - Country:US
Practice Address - Phone:317-621-0668
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-05-30
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA390200000X
IN01086218A2086X0206X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086X0206XAllopathic & Osteopathic PhysiciansSurgerySurgical Oncology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN300052400Medicaid