Provider Demographics
NPI:1528178969
Name:LEE, ERNY (OD)
Entity Type:Individual
Prefix:
First Name:ERNY
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 1:2060 PEABODY RD
Mailing Address - Street 2:SUTIE 600
Mailing Address - City:VACAVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:95687-6696
Mailing Address - Country:US
Mailing Address - Phone:707-448-0163
Mailing Address - Fax:707-448-5321
Practice Address - Street 1:2060 PEABODY RD
Practice Address - Street 2:SUTIE 600
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95687-6696
Practice Address - Country:US
Practice Address - Phone:707-448-0163
Practice Address - Fax:707-448-5321
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6489T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0064890Medicaid
CAT10337Medicare UPIN
CASD0064890Medicare ID - Type UnspecifiedMEDICARE