Provider Demographics
NPI:1366503005
Name:LEE, GEORGE W III (OD)
Entity Type:Individual
Prefix:DR
First Name:GEORGE
Middle Name:W
Last Name:LEE
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2004 W 15TH ST
Mailing Address - Street 2:SUITE 2
Mailing Address - City:LOVELAND
Mailing Address - State:CO
Mailing Address - Zip Code:80538-3596
Mailing Address - Country:US
Mailing Address - Phone:970-669-2040
Mailing Address - Fax:970-669-2041
Practice Address - Street 1:2004 W 15TH ST
Practice Address - Street 2:SUITE 2
Practice Address - City:LOVELAND
Practice Address - State:CO
Practice Address - Zip Code:80538-3596
Practice Address - Country:US
Practice Address - Phone:970-669-2040
Practice Address - Fax:970-669-2041
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-13
Last Update Date:2011-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COCO855152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO04016119Medicaid
COT60720Medicare UPIN
COCO40767Medicare PIN