Provider Demographics
NPI:1699756189
Name:LEE, MICHAEL (DPM)
Entity type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:
Last Name:LEE
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 1:1061 HARMON AVE
Mailing Address - Street 2:STE 1D03
Mailing Address - City:FORT STEWART
Mailing Address - State:GA
Mailing Address - Zip Code:31314-5641
Mailing Address - Country:US
Mailing Address - Phone:912-435-5965
Mailing Address - Fax:912-435-5965
Practice Address - Street 1:1061 HARMON AVE
Practice Address - Street 2:STE 1D03
Practice Address - City:FORT STEWART
Practice Address - State:GA
Practice Address - Zip Code:31314-5641
Practice Address - Country:US
Practice Address - Phone:912-435-5965
Practice Address - Fax:912-435-5965
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2024-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAPO00000732213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8377848Medicaid
WA8866117Medicare PIN
WA8377848Medicaid