Provider Demographics
NPI:1083616288
Name:LEE, EDWARD SEUNGHO (OD)
Entity Type:Individual
Prefix:DR
First Name:EDWARD
Middle Name:SEUNGHO
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:32020 32ND AVE S
Mailing Address - Street 2:STE 130
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98001-9625
Mailing Address - Country:US
Mailing Address - Phone:253-839-0600
Mailing Address - Fax:253-941-7485
Practice Address - Street 1:32020 32ND AVE S
Practice Address - Street 2:STE 130
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98001-9625
Practice Address - Country:US
Practice Address - Phone:253-839-0600
Practice Address - Fax:253-941-7485
Is Sole Proprietor?:Yes
Enumeration Date:2005-06-01
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAWA2011152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2013498Medicaid
WAU28362Medicare UPIN
WA000100055Medicare ID - Type Unspecified