Healthcare Provider Details

I. General information

NPI: 1033157912
Provider Name (Legal Business Name): MICHAEL LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/03/2006
Last Update Date: 10/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

640 HAWKINS AVE
LAKE RONKONKOMA NY
11779-2324
US

IV. Provider business mailing address

1000 ZECKENDORF BLVD
GARDEN CITY NY
11530-2133
US

V. Phone/Fax

Practice location:
  • Phone: 631-737-0100
  • Fax: 631-417-1117
Mailing address:
  • Phone: 516-542-6880
  • Fax: 516-542-5556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number203155
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: