Provider Demographics
NPI:1497736722
Name:LEE, MIRA V (MD)
Entity type:Individual
Prefix:
First Name:MIRA
Middle Name:V
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1509 RIDGEVIEW DR
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:CO
Mailing Address - Zip Code:80027-1605
Mailing Address - Country:US
Mailing Address - Phone:303-819-2230
Mailing Address - Fax:
Practice Address - Street 1:13421 QUEBEC ST
Practice Address - Street 2:
Practice Address - City:THORNTON
Practice Address - State:CO
Practice Address - Zip Code:80602-8647
Practice Address - Country:US
Practice Address - Phone:303-498-2850
Practice Address - Fax:303-272-0382
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2024-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0038019207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO99627817Medicaid
COP00176058Medicare PIN
COC800026Medicare PIN
CO99627817Medicaid