Provider Demographics
NPI:1427287408
Name:LEE, EARL (DO)
Entity type:Individual
Prefix:
First Name:EARL
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 8100
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97303-0900
Mailing Address - Country:US
Mailing Address - Phone:503-399-2424
Mailing Address - Fax:503-315-4608
Practice Address - Street 1:2020 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-0644
Practice Address - Country:US
Practice Address - Phone:503-399-2470
Practice Address - Fax:503-375-7429
Is Sole Proprietor?:No
Enumeration Date:2009-07-10
Last Update Date:2012-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOT013000207Q00000X
ORDO156914207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR1228590005Medicare NSC
ORR164665Medicare PIN