Provider Demographics
NPI:1073878328
Name:LEE, YI SAN (OD)
Entity Type:Individual
Prefix:DR
First Name:YI SAN
Middle Name:
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 1:13620 38TH AVE STE 7G
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-4232
Mailing Address - Country:US
Mailing Address - Phone:718-395-8080
Mailing Address - Fax:
Practice Address - Street 1:13620 38TH AVE STE 7G
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-4232
Practice Address - Country:US
Practice Address - Phone:718-395-8080
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-11
Last Update Date:2014-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007839-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist