Healthcare Provider Details

I. General information

NPI: 1912586488
Provider Name (Legal Business Name): SAMUEL LEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2021
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11104 PARKVIEW CIRCLE DR STE 110
FORT WAYNE IN
46845-1673
US

IV. Provider business mailing address

PO BOX 50095
SEATTLE WA
98145-5095
US

V. Phone/Fax

Practice location:
  • Phone: 260-425-6780
  • Fax: 260-425-6615
Mailing address:
  • Phone: 206-520-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2084N0400X
TaxonomyNeurology Physician
License Number02009193A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: