Provider Demographics
NPI:1891789368
Name:CARTER, LEE JAMES (OD)
Entity Type:Individual
Prefix:DR
First Name:LEE
Middle Name:JAMES
Last Name:CARTER
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 1:2745 AMERICAN LEGION BLVD
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN HOME
Mailing Address - State:ID
Mailing Address - Zip Code:83647-3185
Mailing Address - Country:US
Mailing Address - Phone:208-587-0974
Mailing Address - Fax:208-587-0994
Practice Address - Street 1:2745 AMERICAN LEGION BLVD
Practice Address - Street 2:
Practice Address - City:MOUNTAIN HOME
Practice Address - State:ID
Practice Address - Zip Code:83647-3185
Practice Address - Country:US
Practice Address - Phone:208-587-0974
Practice Address - Fax:208-587-0994
Is Sole Proprietor?:No
Enumeration Date:2005-09-09
Last Update Date:2013-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-100084152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807254900Medicaid
ID807254900Medicaid
ID1594515Medicare PIN