Provider Demographics
NPI:1740221266
Name:LEE, LINDA (OD)
Entity Type:Individual
Prefix:
First Name:LINDA
Middle Name:
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 1:3104 W OLYMPIC BLVD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90006-2414
Mailing Address - Country:US
Mailing Address - Phone:213-487-1001
Mailing Address - Fax:213-487-1023
Practice Address - Street 1:3104 W OLYMPIC BLVD
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90006-2414
Practice Address - Country:US
Practice Address - Phone:213-487-1001
Practice Address - Fax:213-487-1023
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-08
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA11073T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0110730Medicaid
CACA1073OtherEYEMED INSURANCE
CA13087OtherMEDICAL EYE SERVICES
CAOP11073Medicare ID - Type Unspecified
CAU75538Medicare UPIN