Provider Demographics
NPI:1508876814
Name:HALSTED, LEE H (OD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:H
Last Name:HALSTED
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 1:4136 MERRIMAN LOOP
Mailing Address - Street 2:
Mailing Address - City:HOWELL
Mailing Address - State:MI
Mailing Address - Zip Code:48843-5210
Mailing Address - Country:US
Mailing Address - Phone:517-552-1195
Mailing Address - Fax:517-552-1195
Practice Address - Street 1:3405 S LINDEN RD
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48507-3009
Practice Address - Country:US
Practice Address - Phone:810-732-4110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2010-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901002594152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MILH002594OtherBCBS IDENTIFICATION
MIMI2594OtherEYEMED IDENTIFICATION
MI944481850Medicaid
MIMI2594OtherEYEMED IDENTIFICATION