Provider Demographics
NPI:1255919031
Name:LEE, JASON KANG
Entity type:Individual
Prefix:
First Name:JASON
Middle Name:KANG
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 ENTERPRISE STE 200
Mailing Address - Street 2:
Mailing Address - City:ALISO VIEJO
Mailing Address - State:CA
Mailing Address - Zip Code:92656-2626
Mailing Address - Country:US
Mailing Address - Phone:949-688-6205
Mailing Address - Fax:949-688-6205
Practice Address - Street 1:3155 SEDONA CT STE 100
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-6558
Practice Address - Country:US
Practice Address - Phone:909-698-9780
Practice Address - Fax:909-974-0356
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-01
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA34847152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist