Provider Demographics
NPI:1417045949
Name:LEE, SUSAN (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
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 1:215 N CLARENCE NASH BLVD
Mailing Address - Street 2:
Mailing Address - City:WATONGA
Mailing Address - State:OK
Mailing Address - Zip Code:73772-3645
Mailing Address - Country:US
Mailing Address - Phone:580-623-2300
Mailing Address - Fax:580-623-7533
Practice Address - Street 1:215 N CLARENCE NASH BLVD
Practice Address - Street 2:
Practice Address - City:WATONGA
Practice Address - State:OK
Practice Address - Zip Code:73772-3645
Practice Address - Country:US
Practice Address - Phone:580-623-2300
Practice Address - Fax:580-623-7533
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-10
Last Update Date:2010-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK1010152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK1010OtherLICENSE
OK100760870AMedicaid
1212030001Medicare NSC
OK100760870AMedicaid