Provider Demographics
NPI:1629278148
Name:LEE, THOMAS KAN (OD)
Entity Type:Individual
Prefix:DR
First Name:THOMAS
Middle Name:KAN
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:14601 VALLEY CENTER DRIVE
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-4216
Mailing Address - Country:US
Mailing Address - Phone:760-955-8228
Mailing Address - Fax:760-241-5702
Practice Address - Street 1:14601 VALLEY CENTER DRIVE
Practice Address - Street 2:
Practice Address - City:VICTORVILLE
Practice Address - State:CA
Practice Address - Zip Code:92392-4216
Practice Address - Country:US
Practice Address - Phone:760-955-8228
Practice Address - Fax:760-241-5702
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-23
Last Update Date:2007-07-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8529152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist