Individual
DR. LEE G THEOPHELIS
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
MD
Contact information
Practice address
1350 HICKORY ST, MELBOURNE, FL 32901-3224
(321) 434-1401
(321) 434-1667
Mailing address
3300 S FISKE BLVD, ROCKLEDGE, FL 32955-4306
Taxonomy
Speciality
Code
Description
License number
State
2086S0122X
Plastic and Reconstructive Surgery Physician
Primary
ME59792
FL
2086S0127X
Trauma Surgery Physician
ME59792
FL
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
18869V
FL MEDICARE
FL
01
—
18869W
FL MEDICARE
FL
05
—
372847100
—
FL
Enumeration date
05/26/2006
Last updated
11/03/2023
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