Healthcare Provider Details

I. General information

NPI: 1962494484
Provider Name (Legal Business Name): MAXIMILIAN SAMUEL LEE MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/19/2005
Last Update Date: 08/13/2025
Certification Date: 08/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4881 SUGAR MAPLE DR
WRIGHT PATTERSON AFB OH
45433-5529
US

IV. Provider business mailing address

RAF LAKENHEATH 48 MDG/SGHC UNIT 5115
APO AE
09461-5115
US

V. Phone/Fax

Practice location:
  • Phone: 937-938-3133
  • Fax:
Mailing address:
  • Phone: 314-226-8124
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207P00000X
TaxonomyEmergency Medicine Physician
License NumberL5019
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License NumberL5019
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2083A0100X
TaxonomyAerospace Medicine Physician
License Number35.076905
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: