Provider Demographics
NPI:1427180553
Name:LEE, SHERYL WATSON (OD)
Entity Type:Individual
Prefix:DR
First Name:SHERYL
Middle Name:WATSON
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 1:6844 HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:AMITE
Mailing Address - State:LA
Mailing Address - Zip Code:70422-8232
Mailing Address - Country:US
Mailing Address - Phone:601-823-4494
Mailing Address - Fax:601-823-4551
Practice Address - Street 1:960 BROOKWAY BLVD
Practice Address - Street 2:
Practice Address - City:BROOKHAVEN
Practice Address - State:MS
Practice Address - Zip Code:39601-2644
Practice Address - Country:US
Practice Address - Phone:601-823-4494
Practice Address - Fax:601-823-4551
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS587-94115152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00880040Medicaid
MS00880040Medicaid
U59386Medicare UPIN