Provider Demographics
NPI:1073702718
Name:LEE, MIJA JACKSON
Entity Type:Individual
Prefix:DR
First Name:MIJA
Middle Name:JACKSON
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:DR
Other - First Name:MIJA
Other - Middle Name:JACKSON
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:250 W. HWY 67
Mailing Address - Street 2:
Mailing Address - City:DUNCANVILLE
Mailing Address - State:TX
Mailing Address - Zip Code:75137
Mailing Address - Country:US
Mailing Address - Phone:972-572-9555
Mailing Address - Fax:
Practice Address - Street 1:250 W. HWY 67
Practice Address - Street 2:
Practice Address - City:DUNCANVILLE
Practice Address - State:TX
Practice Address - Zip Code:75137
Practice Address - Country:US
Practice Address - Phone:972-572-9555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-10-18
Last Update Date:2010-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX6034TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX614187Medicare PIN