1316966971 NPI number — ALBERT C LEE MD

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1316966971 NPI number — ALBERT C LEE MD

Employer Identification Number (EIN):

Provider Organization Name:

Provider Last Name:

LEE

Provider First Name:

ALBERT

Provider Middle Name:

C

Provider Name Prefix Text:

Provider Name Suffix Text:

Provider Credential Text:

MD

Provider Gender Code:

M

Provider Other Organization Name:

Provider Other Organization Name Type Code:

Provider Other Last Name:

Provider Other First Name:

Provider Other Middle Name:

Provider Other Name Prefix Text:

Provider Other Name Suffix Text:

Provider Other Credential Text:

Provider Other Last Name Type Code:

NPI Number:

1316966971

Entity Type Code:

Individual

Replacement NPI:

Last Update Date:

01/04/2016

NPI Deactivation Reason Code:

NPI Deactivation Date:

NPI Reactivation Date:

Provider First Line Business Mailing Address:

PO BOX 846098

Provider Second Line Business Mailing Address:

Provider Business Mailing Address City Name:

DALLAS

Provider Business Mailing Address State Name:

TX

Provider Business Mailing Address Postal Code:

75284-6098

Provider Business Mailing Address Country Code:

US

Provider Business Mailing Address Telephone Number:

903-324-6450

Provider Business Mailing Address Fax Number:

Provider First Line Business Practice Location Address:

520 E DOUGLAS BLVD

Provider Second Line Business Practice Location Address:

Provider Business Practice Location Address City Name:

TYLER

Provider Business Practice Location Address State Name:

TX

Provider Business Practice Location Address Postal Code:

75702-8307

Provider Business Practice Location Address Country Code:

US

Provider Business Practice Location Address Telephone Number:

903-593-1721

Provider Business Practice Location Address Fax Number:

Provider Enumeration Date:

07/18/2006

Authorized Official Last Name:

Authorized Official First Name:

Authorized Official Middle Name:

Authorized Official Title or Position:

Authorized Official Telephone Number:

• Taxonomy code: 174400000X , with the licence number:  G58417 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
• Taxonomy code: 2085R0202X , with the licence number: N0916 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

• Identifier: 196640002 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 8CU212 . This is a "BCBS JV LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 196640001 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: 196640003 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: TIN PLUS 113 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 196640004 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".
• Identifier: TIN PLUS 013 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8BC077 . This is a "BCBS OF TEXAS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: 8AP484 . This is a "BCBS" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: TIN PLUS 005 . This is a "TRICARE JV LOCATION" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".
• Identifier: TIN PLUS 007 . This is a "TRICARE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".