Provider Demographics
NPI:1861413536
Name:LEE, MARK ROBERT (MD)
Entity type:Individual
Prefix:DR
First Name:MARK
Middle Name:ROBERT
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 1:333 N SANTA ROSA
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78207-3108
Mailing Address - Country:US
Mailing Address - Phone:210-704-4100
Mailing Address - Fax:
Practice Address - Street 1:40 MEDICAL PARK STE 508
Practice Address - Street 2:
Practice Address - City:WHEELING
Practice Address - State:WV
Practice Address - Zip Code:26003
Practice Address - Country:US
Practice Address - Phone:304-243-8916
Practice Address - Fax:304-243-7194
Is Sole Proprietor?:No
Enumeration Date:2006-07-21
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV28512207T00000X
GA039151207T00000X
SC27496207T00000X
TXN21672086S0120X, 207T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207T00000XAllopathic & Osteopathic PhysiciansNeurological Surgery
No2086S0120XAllopathic & Osteopathic PhysiciansSurgeryPediatric Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA000618032EMedicaid
GAGRP8134OtherMEDICARE GROUP#
GA14BDHMKMedicare PIN
GA000618032EMedicaid
SCF708437706Medicare ID - Type UnspecifiedSOUTH CAROLINA MEDICARE