Provider Demographics
NPI:1407859853
Name:LEE, JOHN T (OD)
Entity Type:Individual
Prefix:DR
First Name:JOHN
Middle Name:T
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5118 PARK AVE
Mailing Address - Street 2:STE 101
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38117-5710
Mailing Address - Country:US
Mailing Address - Phone:901-683-4529
Mailing Address - Fax:901-767-4404
Practice Address - Street 1:5118 PARK AVE
Practice Address - Street 2:STE 101
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38117-5710
Practice Address - Country:US
Practice Address - Phone:901-683-4529
Practice Address - Fax:901-767-4404
Is Sole Proprietor?:Yes
Enumeration Date:2005-05-31
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNOD396152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN410009154OtherMEDICARE RAILROAD
TN410009154OtherMEDICARE RAILROAD
TNU01081Medicare UPIN