Provider Demographics
NPI:1174636914
Name:LEE, MICHAEL EUNTAEK (OD)
Entity Type:Individual
Prefix:DR
First Name:MICHAEL
Middle Name:EUNTAEK
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 1:2672 LUNDQUIST DR
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60503-3653
Mailing Address - Country:US
Mailing Address - Phone:630-730-8888
Mailing Address - Fax:
Practice Address - Street 1:200 S BOLINGBROOK DR
Practice Address - Street 2:
Practice Address - City:BOLINGBROOK
Practice Address - State:IL
Practice Address - Zip Code:60440-2932
Practice Address - Country:US
Practice Address - Phone:630-739-4891
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU96122Medicare UPIN
ILK32193Medicare ID - Type UnspecifiedINDIVIDUAL
IL214315Medicare ID - Type UnspecifiedGROUP