Provider Demographics
NPI:1073559233
Name:LEE-VILLANUEVA, BETTY WAI-HAN (OD)
Entity Type:Individual
Prefix:DR
First Name:BETTY
Middle Name:WAI-HAN
Last Name:LEE-VILLANUEVA
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 1:330 N BRAND BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:GLENDALE
Mailing Address - State:CA
Mailing Address - Zip Code:91203-2308
Mailing Address - Country:US
Mailing Address - Phone:866-260-2020
Mailing Address - Fax:
Practice Address - Street 1:330 N BRAND BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:GLENDALE
Practice Address - State:CA
Practice Address - Zip Code:91203-2308
Practice Address - Country:US
Practice Address - Phone:866-260-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-22
Last Update Date:2010-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11366T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA041522OtherCOLE PROVIDER NUMBER
CA1306035118Medicaid
CA9362933OtherMEDICAL
CADP2509Medicare PIN
CA041522OtherCOLE PROVIDER NUMBER
CA1306035118Medicaid
CA6191070001Medicare NSC
SD0113660Medicare PIN
CABF492AMedicare PIN
CABF523ZMedicare PIN
CAU85601Medicare ID - Type Unspecified