Provider Demographics
NPI:1669502308
Name:LEE, CHUNG HEE (OD)
Entity Type:Individual
Prefix:
First Name:CHUNG
Middle Name:HEE
Last Name:LEE
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 1:63 VAN HOLTEN RD
Mailing Address - Street 2:
Mailing Address - City:BASKING RIDGE
Mailing Address - State:NJ
Mailing Address - Zip Code:07920-3438
Mailing Address - Country:US
Mailing Address - Phone:908-350-3234
Mailing Address - Fax:
Practice Address - Street 1:786 BROAD ST
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:NJ
Practice Address - Zip Code:07102-3728
Practice Address - Country:US
Practice Address - Phone:973-642-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJOA 05329152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ7158106Medicaid
596761Medicare ID - Type Unspecified
NJ7158106Medicaid