Healthcare Provider Details

I. General information

NPI: 1063040574
Provider Name (Legal Business Name): KENNETH ALSTON LEE DO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/30/2020
Last Update Date: 07/24/2023
Certification Date: 06/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4460 S LINDBERGH BLVD
SAINT LOUIS MO
63127-1647
US

IV. Provider business mailing address

4660 SOUTH LINDBERGH
SAINT LOUIS MO
63127
US

V. Phone/Fax

Practice location:
  • Phone: 573-359-4485
  • Fax:
Mailing address:
  • Phone: 314-843-7557
  • Fax: 314-849-8671

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2020019424
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: