Provider Demographics
NPI:1548740517
Name:LEE, JENNIFER (OD)
Entity Type:Individual
Prefix:DR
First Name:JENNIFER
Middle Name:
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 1:1925 BRICKELL AVE
Mailing Address - Street 2:STE D301
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33129-2939
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8590 SW 24TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33155-2336
Practice Address - Country:US
Practice Address - Phone:302-223-2880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-18
Last Update Date:2021-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOCP5576207W00000X
FLOPC5576152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLOPC5576OtherNON-MEDICARE