Provider Demographics
NPI:1235126129
Name:LEE, PRISCILLA (OD)
Entity Type:Individual
Prefix:DR
First Name:PRISCILLA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:1781 E HIGHWAY 69
Practice Address - Street 2:SUITE 55
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-5666
Practice Address - Country:US
Practice Address - Phone:928-776-3096
Practice Address - Fax:928-776-7917
Is Sole Proprietor?:No
Enumeration Date:2005-10-05
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COOPT.0003886152W00000X
PAOEG003988152W00000X
AZ1143152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162077Medicare PIN
AZU99739Medicare UPIN
AZZ163015Medicare PIN
AZZ162074Medicare PIN
AZZ79635Medicare PIN