Provider Demographics
NPI:1891987673
Name:LEE, JEFFERY WILLIAM (DIHOM-COT)
Entity Type:Individual
Prefix:MR
First Name:JEFFERY
Middle Name:WILLIAM
Last Name:LEE
Suffix:
Gender:M
Credentials:DIHOM-COT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:301 S BROADWAY AVE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:OK
Mailing Address - Zip Code:74820-5805
Mailing Address - Country:US
Mailing Address - Phone:580-436-6200
Mailing Address - Fax:580-436-4686
Practice Address - Street 1:301 S BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:OK
Practice Address - Zip Code:74820-5805
Practice Address - Country:US
Practice Address - Phone:580-436-6200
Practice Address - Fax:580-436-4686
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2008-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXD3990156FC0801X
OK36344156FX1100X, 246YC3302X
TXD3989156FX1800X
175L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175L00000XOther Service ProvidersHomeopath
No156FC0801XEye and Vision Services ProvidersTechnician/TechnologistContact Lens Fitter
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
No156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No246YC3302XTechnologists, Technicians & Other Technical Service ProvidersSpecialist/Technologist, Health InformationCoding Specialist, Physician Office Based