Provider Demographics
NPI:1053470252
Name:LEE, SPENCER DARRELL (MD)
Entity type:Individual
Prefix:
First Name:SPENCER
Middle Name:DARRELL
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 1:525 NW LAKE WHITNEY PL
Mailing Address - Street 2:SUITE 206
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34986-1605
Mailing Address - Country:US
Mailing Address - Phone:772-878-8885
Mailing Address - Fax:772-878-5898
Practice Address - Street 1:525 NW LAKE WHITNEY PL
Practice Address - Street 2:SUITE 206
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34986-1605
Practice Address - Country:US
Practice Address - Phone:772-878-8885
Practice Address - Fax:772-878-5898
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-06
Last Update Date:2013-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 76643174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLG36268Medicare UPIN
FL44220Medicare ID - Type Unspecified