Provider Demographics
NPI:1295126167
Name:LEE, ELIZABETH JOSEPHINE (OD)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:JOSEPHINE
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1417 ROYAL GROVE LN
Mailing Address - Street 2:
Mailing Address - City:PORT ORANGE
Mailing Address - State:FL
Mailing Address - Zip Code:32129-8620
Mailing Address - Country:US
Mailing Address - Phone:954-665-7358
Mailing Address - Fax:
Practice Address - Street 1:1771 DUNLAWTON AVE
Practice Address - Street 2:
Practice Address - City:PORT ORANGE
Practice Address - State:FL
Practice Address - Zip Code:32127-4757
Practice Address - Country:US
Practice Address - Phone:386-304-3328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-12
Last Update Date:2015-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4924152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist