Provider Demographics
NPI:1114195203
Name:SUSAN LEE
Entity Type:Organization
Organization Name:SUSAN LEE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:SUSAN
Authorized Official - Middle Name:
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:580-623-2300
Mailing Address - Street 1:215 N CLARENCE NASH BLVD
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-3645
Mailing Address - Country:US
Mailing Address - Phone:580-623-2300
Mailing Address - Fax:580-623-7533
Practice Address - Street 1:215 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3645
Practice Address - Country:US
Practice Address - Phone:580-623-2300
Practice Address - Fax:580-623-7533
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-12
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1010332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1212030001Medicare NSC
T40587Medicare UPIN