Provider Demographics
NPI:1679745418
Name:BOTTEM, LEE THEODORE (DO)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:THEODORE
Last Name:BOTTEM
Suffix:
Gender:M
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:4700 W URBANA ST
Mailing Address - Street 2:
Mailing Address - City:BROKEN ARROW
Mailing Address - State:OK
Mailing Address - Zip Code:74012-5997
Mailing Address - Country:US
Mailing Address - Phone:918-290-2300
Mailing Address - Fax:918-290-2310
Practice Address - Street 1:4700 W URBANA ST
Practice Address - Street 2:
Practice Address - City:BROKEN ARROW
Practice Address - State:OK
Practice Address - Zip Code:74012-5997
Practice Address - Country:US
Practice Address - Phone:918-290-2300
Practice Address - Fax:918-290-2310
Is Sole Proprietor?:Yes
Enumeration Date:2008-04-01
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4175207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
I25903Medicare UPIN