Healthcare Provider Details

I. General information

NPI: 1508256108
Provider Name (Legal Business Name): IKE I LEE MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/03/2015
Last Update Date: 02/03/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3101 MEDICAL WAY
SEBRING FL
33870-5548
US

IV. Provider business mailing address

3101 MEDICAL WAY
SEBRING FL
33870-5548
US

V. Phone/Fax

Practice location:
  • Phone: 863-402-0909
  • Fax: 863-402-1090
Mailing address:
  • Phone: 863-402-0909
  • Fax: 863-402-1090

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RG0300X
TaxonomyGeriatric Medicine (Internal Medicine) Physician
License NumberME0072053
License Number StateFL

VIII. Authorized Official

Name: DR. IKE I LEE
Title or Position: OWNER
Credential: M.D.
Phone: 863-402-0909