Provider Demographics
NPI:1558747576
Name:LEE, SUSANNAH (OD)
Entity Type:Individual
Prefix:DR
First Name:SUSANNAH
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 1:339 NW 9TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97209-3306
Mailing Address - Country:US
Mailing Address - Phone:503-219-0023
Mailing Address - Fax:503-219-0024
Practice Address - Street 1:339 NW 9TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97209
Practice Address - Country:US
Practice Address - Phone:503-219-0023
Practice Address - Fax:503-219-0024
Is Sole Proprietor?:No
Enumeration Date:2015-07-31
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3632AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist