Provider Demographics
NPI:1023306248
Name:LEE, LISE G (MD)
Entity type:Individual
Prefix:
First Name:LISE
Middle Name:G
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 1:1005 MISSISSIPPI AVE UNIT E
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63104-2475
Mailing Address - Country:US
Mailing Address - Phone:608-345-9957
Mailing Address - Fax:
Practice Address - Street 1:1005 MISSISSIPPI AVE UNIT E
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63104-2475
Practice Address - Country:US
Practice Address - Phone:608-345-9957
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-07-21
Last Update Date:2023-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036.146492208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics