Provider Demographics
NPI:1821047036
Name:LEE, BERNARD E (OD)
Entity Type:Individual
Prefix:
First Name:BERNARD
Middle Name:E
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 ARMY POST RD
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50315
Mailing Address - Country:US
Mailing Address - Phone:515-287-5565
Mailing Address - Fax:515-287-2540
Practice Address - Street 1:200 ARMY POST RD
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50315
Practice Address - Country:US
Practice Address - Phone:515-287-5565
Practice Address - Fax:515-287-2540
Is Sole Proprietor?:No
Enumeration Date:2006-05-08
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA01900152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA4068528Medicaid
IA1068528Medicaid
IA0068528Medicaid
IA3068528Medicaid
00646Medicare PIN
IA1068528Medicaid
U00953Medicare UPIN
IA3068528Medicaid
09210Medicare PIN
410026267Medicare PIN
00472Medicare PIN
IA0068528Medicaid
00467Medicare PIN