Provider Demographics
NPI:1033791579
Name:LEE, KRISTEN ERIN (OD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:ERIN
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16009 LEGACY RD UNIT 301
Mailing Address - Street 2:
Mailing Address - City:TUSTIN
Mailing Address - State:CA
Mailing Address - Zip Code:92782-2805
Mailing Address - Country:US
Mailing Address - Phone:808-754-2603
Mailing Address - Fax:
Practice Address - Street 1:2800 N MAIN ST UNIT 104
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92705-6616
Practice Address - Country:US
Practice Address - Phone:714-547-8228
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-23
Last Update Date:2022-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT35261-TLG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist