Provider Demographics
NPI:1477115046
Name:LEE, MICAELA ERICA (OD)
Entity Type:Individual
Prefix:
First Name:MICAELA
Middle Name:ERICA
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 1:5017 W HIGHWAY 290
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78735-6703
Mailing Address - Country:US
Mailing Address - Phone:512-957-6001
Mailing Address - Fax:512-503-8466
Practice Address - Street 1:5017 W HIGHWAY 290
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78735-6703
Practice Address - Country:US
Practice Address - Phone:512-957-6001
Practice Address - Fax:512-503-8466
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-03
Last Update Date:2023-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX9672152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty