Provider Demographics
NPI:1093256539
Name:LEE, TYLER ALLEN (OD)
Entity Type:Individual
Prefix:DR
First Name:TYLER
Middle Name:ALLEN
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 1:5255 NW 12TH ST APT 302
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:NE
Mailing Address - Zip Code:68521-4257
Mailing Address - Country:US
Mailing Address - Phone:308-390-6099
Mailing Address - Fax:
Practice Address - Street 1:2500 NORTHVIEW RD
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:NE
Practice Address - Zip Code:68521-1383
Practice Address - Country:US
Practice Address - Phone:402-420-2020
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-16
Last Update Date:2019-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
NE1478152W00000X
WI3479152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program