MEDICARE: DOROTHY T LEE-EVENSON MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207V00000X	Obstetrics & Gynecology Physician	ME126018	FL

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	IK163Z	OTHER	FL	MEDICARE PTAN

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1023019650
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DOROTHY T LEE-EVENSON MD

Provider Business Mailing Address
First Line	:	PO BOX 748817
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-8817
Country	:	US
Telephone Number	:	813-286-0033
Fax Number	:	813-282-1806

Provider Business Practice Location Address
First Line	:	515 S KINGS AVE STE 3000
Second Line	:
City	:	BRANDON
State	:	FL
Zip	:	33511-6060
Country	:	US
Telephone Number	:	813-681-6625
Fax Number	:	813-684-6043

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/04/2005
Last Update Date	:	06/22/2023

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