Provider Demographics
NPI:1568560811
Name:DE ROSA, LEE U (OD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:U
Last Name:DE ROSA
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 1:633 MAIN ST
Mailing Address - Street 2:
Mailing Address - City:LEWISTON
Mailing Address - State:ME
Mailing Address - Zip Code:04240-5938
Mailing Address - Country:US
Mailing Address - Phone:207-783-8243
Mailing Address - Fax:207-783-0021
Practice Address - Street 1:633 MAIN ST
Practice Address - Street 2:
Practice Address - City:LEWISTON
Practice Address - State:ME
Practice Address - Zip Code:04240-5938
Practice Address - Country:US
Practice Address - Phone:207-783-8243
Practice Address - Fax:207-783-0021
Is Sole Proprietor?:No
Enumeration Date:2006-09-20
Last Update Date:2010-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEOPT623152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME048845OtherANTHEM BLUE CROSS
ME5536080001OtherDME
ME125060099Medicaid
ME5536080001OtherDME
MEDE702555Medicare ID - Type Unspecified