Healthcare Provider Details

I. General information

NPI: 1508867656
Provider Name (Legal Business Name): BRIAN J LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2005
Last Update Date: 03/06/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7910 W JEFFERSON BLVD STE 212
FORT WAYNE IN
46804-4159
US

IV. Provider business mailing address

7910 W JEFFERSON BLVD STE 212
FORT WAYNE IN
46804-4159
US

V. Phone/Fax

Practice location:
  • Phone: 260-427-7473
  • Fax: 260-432-3189
Mailing address:
  • Phone: 260-427-7473
  • Fax: 260-432-3189

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208200000X
TaxonomyPlastic Surgery Physician
License Number01040298A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: