Provider Demographics
NPI:1326038993
Name:LEE, CHAN WOO (OD)
Entity Type:Individual
Prefix:DR
First Name:CHAN
Middle Name:WOO
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 1:2790 CABOT DRIVE
Mailing Address - Street 2:SUITE 135
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92883
Mailing Address - Country:US
Mailing Address - Phone:951-277-2774
Mailing Address - Fax:951-271-9754
Practice Address - Street 1:2790 CABOT DRIVE
Practice Address - Street 2:SUITE 135
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92883
Practice Address - Country:US
Practice Address - Phone:951-277-2774
Practice Address - Fax:951-271-9754
Is Sole Proprietor?:No
Enumeration Date:2005-10-25
Last Update Date:2014-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12516TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA8073436Medicaid
CA8073436Medicaid
CAWOP12516AMedicare ID - Type Unspecified