Healthcare Provider Details

I. General information

NPI: 1861614281
Provider Name (Legal Business Name): LARRY E LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2007
Last Update Date: 04/01/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

45 READE PL
POUGHKEEPSIE NY
12601-3947
US

IV. Provider business mailing address

3998 FAIR RIDGE DR
FAIRFAX VA
22033-2921
US

V. Phone/Fax

Practice location:
  • Phone: 845-471-3289
  • Fax:
Mailing address:
  • Phone: 703-295-9360
  • Fax: 703-766-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207LP2900X
TaxonomyPain Medicine (Anesthesiology) Physician
License Number249634
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number0116016790
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: