Provider Demographics
NPI:1679543003
Name:LEE, SUSANA M (OD)
Entity Type:Individual
Prefix:
First Name:SUSANA
Middle Name:M
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 1:2238 31ST ST
Mailing Address - Street 2:
Mailing Address - City:ASTORIA
Mailing Address - State:NY
Mailing Address - Zip Code:11105-2714
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2238 31ST ST
Practice Address - Street 2:
Practice Address - City:ASTORIA
Practice Address - State:NY
Practice Address - Zip Code:11105-2714
Practice Address - Country:US
Practice Address - Phone:718-278-3600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2007-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ27OA00593700152WL0500X
NYTUV007020-1152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02841394Medicaid
NJ0061620Medicaid
NYV02514Medicare UPIN
NJ0061620Medicaid
NY07935HMedicare PIN