Provider Demographics
NPI:1407830029
Name:LEE, AMY MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:AMY
Middle Name:MICHELLE
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:AMY
Other - Middle Name:MICHELLE
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3570 S VAL VISTA DR
Mailing Address - Street 2:SUITE R104
Mailing Address - City:GILBERT
Mailing Address - State:AZ
Mailing Address - Zip Code:85297-7326
Mailing Address - Country:US
Mailing Address - Phone:480-899-2381
Mailing Address - Fax:480-899-1039
Practice Address - Street 1:3570 S VAL VISTA DR
Practice Address - Street 2:SUITE R104
Practice Address - City:GILBERT
Practice Address - State:AZ
Practice Address - Zip Code:85297-7326
Practice Address - Country:US
Practice Address - Phone:480-899-2381
Practice Address - Fax:480-899-1039
Is Sole Proprietor?:No
Enumeration Date:2005-12-06
Last Update Date:2016-04-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1371152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ2177937OtherMEDICARE
AZV01036Medicare UPIN