Provider Demographics
NPI:1255903795
Name:LEE, SHIN (OD)
Entity type:Individual
Prefix:
First Name:SHIN
Middle Name:
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 1:2383 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WALNUT CREEK
Mailing Address - State:CA
Mailing Address - Zip Code:94596-3549
Mailing Address - Country:US
Mailing Address - Phone:530-220-4500
Mailing Address - Fax:
Practice Address - Street 1:491 30TH ST STE 201
Practice Address - Street 2:
Practice Address - City:OAKLAND
Practice Address - State:CA
Practice Address - Zip Code:94609-3235
Practice Address - Country:US
Practice Address - Phone:510-836-2122
Practice Address - Fax:510-836-3773
Is Sole Proprietor?:No
Enumeration Date:2021-07-14
Last Update Date:2023-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35010152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist