Provider Demographics
NPI:1720022106
Name:LEE, GRACE SUE YING MARK (OD)
Entity Type:Individual
Prefix:DR
First Name:GRACE
Middle Name:SUE YING MARK
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:USAMEDDAC
Mailing Address - Street 2:2480 LLEWELLYN AVE
Mailing Address - City:FORT GEORGE G MEADE
Mailing Address - State:MD
Mailing Address - Zip Code:20755
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9600 MAIN ST
Practice Address - Street 2:SUITE H
Practice Address - City:FAIRFAX
Practice Address - State:VA
Practice Address - Zip Code:22031-3798
Practice Address - Country:US
Practice Address - Phone:703-764-3937
Practice Address - Fax:703-764-3986
Is Sole Proprietor?:No
Enumeration Date:2006-06-15
Last Update Date:2024-02-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0618001170152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist