Provider Demographics
NPI:1225080021
Name:LEE, BRANDON DAVID (MD)
Entity Type:Individual
Prefix:DR
First Name:BRANDON
Middle Name:DAVID
Last Name:LEE
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:135 W RAVINE RD
Mailing Address - Street 2:SUITE 2C
Mailing Address - City:KINGSPORT
Mailing Address - State:TN
Mailing Address - Zip Code:37660-3847
Mailing Address - Country:US
Mailing Address - Phone:423-246-7372
Mailing Address - Fax:423-578-4369
Practice Address - Street 1:135 W RAVINE RD
Practice Address - Street 2:SUITE 2C
Practice Address - City:KINGSPORT
Practice Address - State:TN
Practice Address - Zip Code:37660-3847
Practice Address - Country:US
Practice Address - Phone:423-246-7372
Practice Address - Fax:423-578-4369
Is Sole Proprietor?:No
Enumeration Date:2006-05-17
Last Update Date:2012-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV22313207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN103I181026OtherMEDICARE PTAN
TN103I181026OtherMEDICARE PTAN
WV934811Medicare ID - Type UnspecifiedCHARLESTON EYE CARE PLLC