Provider Demographics
NPI:1013909555
Name:LEE, ROBERT FREDRICK III (OD)
Entity Type:Individual
Prefix:DR
First Name:ROBERT
Middle Name:FREDRICK
Last Name:LEE
Suffix:III
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:15157 GRATIOT AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1324
Mailing Address - Country:US
Mailing Address - Phone:313-526-7664
Mailing Address - Fax:313-526-2055
Practice Address - Street 1:15157 GRATIOT AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1324
Practice Address - Country:US
Practice Address - Phone:313-526-7664
Practice Address - Fax:313-526-2055
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-19
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003122152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3289816Medicaid
MI3289816Medicaid
MI1173480001Medicare NSC
MION80400Medicare PIN