Provider Demographics
NPI:1447393012
Name:LEE, SUSAN KIM (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSAN
Middle Name:KIM
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 1:11 GRAPEVINE
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2461
Mailing Address - Country:US
Mailing Address - Phone:714-661-9834
Mailing Address - Fax:714-730-2023
Practice Address - Street 1:3873 PORTOLA PKWY
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602-0828
Practice Address - Country:US
Practice Address - Phone:714-730-2020
Practice Address - Fax:714-730-2023
Is Sole Proprietor?:No
Enumeration Date:2007-02-14
Last Update Date:2013-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10993T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist