Provider Demographics
NPI:1295899177
Name:BERMAN, LEE S (OD)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:S
Last Name:BERMAN
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 1:1365 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:
Practice Address - Street 1:11642 KNOTT ST STE 15
Practice Address - Street 2:
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92841-1820
Practice Address - Country:US
Practice Address - Phone:714-903-7767
Practice Address - Fax:714-903-7801
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-21
Last Update Date:2015-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACA5638T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOP5638AMedicare PIN
CAT10063Medicare UPIN