Provider Demographics
NPI:1134115116
Name:LEE, JOHN (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:101 INDEPENDENCE MALL WAY
Mailing Address - Street 2:C 104
Mailing Address - City:KINGSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02364-3048
Mailing Address - Country:US
Mailing Address - Phone:781-585-1668
Mailing Address - Fax:781-582-3872
Practice Address - Street 1:101 INDEPENDENCE MALL WAY
Practice Address - Street 2:C 104
Practice Address - City:KINGSTON
Practice Address - State:MA
Practice Address - Zip Code:02364-3048
Practice Address - Country:US
Practice Address - Phone:781-585-1668
Practice Address - Fax:781-582-3872
Is Sole Proprietor?:Yes
Enumeration Date:2005-09-23
Last Update Date:2010-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA4502152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW17587Medicare PIN