Provider Demographics
NPI:1760656417
Name:GARY LEE OD
Entity Type:Organization
Organization Name:GARY LEE OD
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OPTOMETRIST
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:A
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:626-442-6620
Mailing Address - Street 1:10614 LOWER AZUSA RD
Mailing Address - Street 2:
Mailing Address - City:EL MONTE
Mailing Address - State:CA
Mailing Address - Zip Code:91731-1210
Mailing Address - Country:US
Mailing Address - Phone:626-442-6620
Mailing Address - Fax:626-442-5803
Practice Address - Street 1:10614 LOWER AZUSA RD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91731-1210
Practice Address - Country:US
Practice Address - Phone:626-442-6620
Practice Address - Fax:626-442-5803
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-14
Last Update Date:2008-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOP5893T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAGSD005670Medicaid