MEDICARE: SAMUEL C LEE DO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	K0107	TX

General Provider Information

NPI Number	:	1770508376
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SAMUEL C LEE DO

Provider Business Mailing Address
First Line	:	1412 MAY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7639
Country	:	US
Telephone Number	:	817-625-8818
Fax Number	:	817-625-7850

Provider Business Practice Location Address
First Line	:	1412 MAY ST
Second Line	:
City	:	FORT WORTH
State	:	TX
Zip	:	76104-7639
Country	:	US
Telephone Number	:	817-625-8818
Fax Number	:	817-625-7850

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/13/2006
Last Update Date	:	12/19/2023

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Directions to “ SAMUEL C LEE DO” Practice Location

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