Healthcare Provider Details

I. General information

NPI: 1285861393
Provider Name (Legal Business Name): MICHAEL MARTIN LEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/16/2009
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4801 VETERANS DR
SAINT CLOUD MN
56303-2015
US

IV. Provider business mailing address

10349 34TH ST NE
SAINT MICHAEL MN
55376-8488
US

V. Phone/Fax

Practice location:
  • Phone: 320-252-1670
  • Fax:
Mailing address:
  • Phone: 559-770-1787
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number2010-01706
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2010-01706
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number2010-01706
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: