Healthcare Provider Details

I. General information

NPI: 1942405501
Provider Name (Legal Business Name): LEE K GOLD DPM PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/15/2007
Last Update Date: 01/23/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5889 WHITMORE LAKE RD STE A
BRIGHTON MI
48116-1998
US

IV. Provider business mailing address

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

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberLG400121
License Number StateMI

VIII. Authorized Official

Name: LEE KEVIN GOLD
Title or Position: OWNER
Credential:
Phone: 810-227-4155