=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326006479
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | WILFRED KWONG LEE M.D.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2006
-----------------------------------------------------
Last Update Date | 08/14/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 13650 METROPOLIS AVENUE SUITE 101
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-768-2111
-----------------------------------------------------
Fax | 239-768-2113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 12550 PROFESSIONAL PARK DRIVE SUITE 11
-----------------------------------------------------
City | FORT MYERS
-----------------------------------------------------
State | FL
-----------------------------------------------------
Zip | 33913
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 239-768-2111
-----------------------------------------------------
Fax | 239-482-4404
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | ME71067
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------