Provider Demographics
NPI:1619762770
Name:LEE, DERRICK TAK (PMD, FPC)
Entity type:Individual
Prefix:
First Name:DERRICK
Middle Name:TAK
Last Name:LEE
Suffix:
Gender:M
Credentials:PMD, FPC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2390 N AIRPORT RD
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-1426
Mailing Address - Country:US
Mailing Address - Phone:561-436-0004
Mailing Address - Fax:
Practice Address - Street 1:2390 N AIRPORT RD
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-1426
Practice Address - Country:US
Practice Address - Phone:561-436-0004
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-10
Last Update Date:2025-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPMD520178207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services