Provider Demographics
NPI:1518093160
Name:LEE, SO YEON (OD, FAAO)
Entity Type:Individual
Prefix:DR
First Name:SO YEON
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:OD, FAAO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 290370
Mailing Address - Street 2:
Mailing Address - City:DAVIE
Mailing Address - State:FL
Mailing Address - Zip Code:33329-0370
Mailing Address - Country:US
Mailing Address - Phone:954-262-4397
Mailing Address - Fax:
Practice Address - Street 1:3200 S. UNIVERSITY DRIVE
Practice Address - Street 2:
Practice Address - City:FT. LAUDERDALE
Practice Address - State:FL
Practice Address - Zip Code:33328-2018
Practice Address - Country:US
Practice Address - Phone:954-262-4200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2018-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2697152WL0500X
FLOFC68152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL014142700Medicaid