Healthcare Provider Details

I. General information

NPI: 1619036993
Provider Name (Legal Business Name): CONSTANCE W LEE MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/06/2006
Last Update Date: 06/28/2023
Certification Date: 06/28/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 CHILDRENS PL STE A STE A
SAINT LOUIS MO
63110-1002
US

IV. Provider business mailing address

660 S EUCLID AVE C B 8235
SAINT LOUIS MO
63110-1010
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6070
  • Fax: 314-454-2442
Mailing address:
  • Phone: 314-454-6070
  • Fax: 314-454-2442

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number2016013269
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code2086S0120X
TaxonomyPediatric Surgery Physician
License NumberMD215943
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: