Provider Demographics
NPI:1346562659
Name:LEE, JIMIN (OD)
Entity Type:Individual
Prefix:
First Name:JIMIN
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 1:1350 ROSE ST
Mailing Address - Street 2:UNIT A
Mailing Address - City:BERKELEY
Mailing Address - State:CA
Mailing Address - Zip Code:94702-1108
Mailing Address - Country:US
Mailing Address - Phone:510-439-6249
Mailing Address - Fax:
Practice Address - Street 1:100 N WIGET LN STE 270
Practice Address - Street 2:
Practice Address - City:WALNUT CREEK
Practice Address - State:CA
Practice Address - Zip Code:94598-5901
Practice Address - Country:US
Practice Address - Phone:925-705-7299
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-02-28
Last Update Date:2019-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13779152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist