Healthcare Provider Details

I. General information

NPI: 1306925136
Provider Name (Legal Business Name): LEE KEVIN GOLD DPM
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2006
Last Update Date: 04/23/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5889 WHITMORE LAKE RD SUITE 1
BRIGHTON MI
48116-1998
US

IV. Provider business mailing address

6647 BRISTOL DR
WEST BLOOMFIELD MI
48322-3263
US

V. Phone/Fax

Practice location:
  • Phone: 810-227-4155
  • Fax: 810-227-0845
Mailing address:
  • Phone: 248-661-1974
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberLG400121
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License Number5401400121
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: