Provider Demographics
NPI:1972620409
Name:LEE, NICOLA B (MD)
Entity type:Individual
Prefix:
First Name:NICOLA
Middle Name:B
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5080 SPECTRUM DRIVE
Mailing Address - Street 2:SUITE 1200 WEST TOWER
Mailing Address - City:ADDISON
Mailing Address - State:TX
Mailing Address - Zip Code:75001
Mailing Address - Country:US
Mailing Address - Phone:800-232-3550
Mailing Address - Fax:
Practice Address - Street 1:3580 ATLANTA AVE
Practice Address - Street 2:
Practice Address - City:HAPEVILLE
Practice Address - State:GA
Practice Address - Zip Code:30354-1706
Practice Address - Country:US
Practice Address - Phone:615-778-4066
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA0521062083P0500X, 208D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No2083P0500XAllopathic & Osteopathic PhysiciansPreventive MedicinePreventive Medicine/Occupational Environmental Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA511G700201Medicare PIN
GA202I110858Medicare UPIN
GA511I110228Medicare UPIN