Provider Demographics
NPI:1376660555
Name:LEE, SOO MI (O D)
Entity Type:Individual
Prefix:DR
First Name:SOO MI
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:O D
Other - Prefix:DR
Other - First Name:SOO
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:O D
Mailing Address - Street 1:800 MAGNOLIA AVE
Mailing Address - Street 2:9
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3583
Mailing Address - Country:US
Mailing Address - Phone:714-469-5556
Mailing Address - Fax:714-578-5715
Practice Address - Street 1:1839 W ORANGETHORPE AVE
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-4405
Practice Address - Country:US
Practice Address - Phone:714-879-2020
Practice Address - Fax:714-525-7138
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA12607T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist