Provider Demographics
NPI:1619196128
Name:LEE, LAURA H (OD)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:H
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:KYUNG
Other - Middle Name:H
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:28815 PACIFIC HWY S
Mailing Address - Street 2:SUITE 2
Mailing Address - City:FEDERAL WAY
Mailing Address - State:WA
Mailing Address - Zip Code:98003
Mailing Address - Country:US
Mailing Address - Phone:253-941-7074
Mailing Address - Fax:253-941-5079
Practice Address - Street 1:28815 PACIFIC HWY S
Practice Address - Street 2:STE 2
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-3876
Practice Address - Country:US
Practice Address - Phone:253-941-7074
Practice Address - Fax:253-941-5079
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2011-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAOD00002095152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2015147Medicaid
WA0217194OtherLABOR AND INDUSTRIES
WA2015147Medicaid
WA0217194OtherLABOR AND INDUSTRIES