Provider Demographics
NPI:1508929407
Name:LEE, DAVID (OD)
Entity Type:Individual
Prefix:
First Name:DAVID
Middle Name:
Last Name:LEE
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 1:8351 ELK GROVE BLVD.
Mailing Address - Street 2:SUITE 200
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-5515
Mailing Address - Country:US
Mailing Address - Phone:916-683-1222
Mailing Address - Fax:
Practice Address - Street 1:8351 ELK GROVE BLVD.
Practice Address - Street 2:SUITE 200
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-5515
Practice Address - Country:US
Practice Address - Phone:916-683-1222
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA9648T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0096480Medicaid
CASD0096481Medicare ID - Type Unspecified