MEDICARE: DR. DAVID ETHAN LEE M.D.

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	207Q00000X	Family Medicine Physician	2006-00237	NC

Other Identifiers

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

General Provider Information

NPI Number	:	1578511911
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. DAVID ETHAN LEE M.D.

Provider Business Mailing Address
First Line	:	PO BOX 751803
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28275-1803
Country	:	US
Telephone Number	:	336-712-0700
Fax Number	:	336-712-0876

Provider Business Practice Location Address
First Line	:	7130 VILLAGE MEDICAL CIR
Second Line	:
City	:	CLEMMONS
State	:	NC
Zip	:	27012-8004
Country	:	US
Telephone Number	:	336-893-2420
Fax Number	:	336-893-2431

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

Provider Enumeration Date	:	05/05/2006
Last Update Date	:	10/28/2020

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