Provider Demographics
NPI:1053409797
Name:LEE, LOUIS (MD)
Entity type:Individual
Prefix:
First Name:LOUIS
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 403631
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30384-3631
Mailing Address - Country:US
Mailing Address - Phone:770-740-0895
Mailing Address - Fax:770-740-0896
Practice Address - Street 1:2801 DEKALB MEDICAL PKWY
Practice Address - Street 2:
Practice Address - City:LITHONIA
Practice Address - State:GA
Practice Address - Zip Code:30058-4996
Practice Address - Country:US
Practice Address - Phone:404-501-8492
Practice Address - Fax:404-501-8645
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2008-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA038840208M00000X
GA38840207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
Provider Identifiers
StateIdentifier IDID TypeIssuer
GAP00392996OtherRR MCARE
GA000675001IMedicaid
GAG14966Medicare UPIN
GAP00392996OtherRR MCARE