Provider Demographics
NPI:1245531425
Name:DR LEE S BERMAN OPTOMETRY INC
Entity type:Organization
Organization Name:DR LEE S BERMAN OPTOMETRY INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE OWNER/CEO
Authorized Official - Prefix:
Authorized Official - First Name:LEE
Authorized Official - Middle Name:S
Authorized Official - Last Name:BERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:949-933-7301
Mailing Address - Street 1:1365 DIVINITY DR
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-7406
Mailing Address - Country:US
Mailing Address - Phone:949-933-7301
Mailing Address - Fax:714-903-7801
Practice Address - Street 1:1661 GOLDEN RAIN RD
Practice Address - Street 2:
Practice Address - City:SEAL BEACH
Practice Address - State:CA
Practice Address - Zip Code:90740-4907
Practice Address - Country:US
Practice Address - Phone:949-933-7301
Practice Address - Fax:714-903-7801
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-04
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA5638T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP5638AMedicare PIN