Provider Demographics
NPI:1962401869
Name:LEE, ROBERT (MD)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:
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 1:53822 GENERATIONS DR
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46635-1543
Mailing Address - Country:US
Mailing Address - Phone:574-233-3711
Mailing Address - Fax:574-288-1702
Practice Address - Street 1:53822 GENERATIONS DR
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46635-1543
Practice Address - Country:US
Practice Address - Phone:574-233-3711
Practice Address - Fax:574-288-1702
Is Sole Proprietor?:No
Enumeration Date:2005-07-21
Last Update Date:2017-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01048726A207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
No207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4134100Medicaid
IN200182540Medicaid
IN200883090AMedicaid
IN000000093609OtherBLUE SHIELD
IN000000550384OtherANTHEM
IN255360AMedicare PIN
IN139900Medicare PIN
MI4134100Medicaid