Provider Demographics
NPI:1336615764
Name:MCKINNEY, LEE ROBERT (LO)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:ROBERT
Last Name:MCKINNEY
Suffix:
Gender:M
Credentials:LO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:495 HAWLEY LN
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-1514
Mailing Address - Country:US
Mailing Address - Phone:203-375-5819
Mailing Address - Fax:203-377-4337
Practice Address - Street 1:495 HAWLEY LN
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-1514
Practice Address - Country:US
Practice Address - Phone:203-375-5819
Practice Address - Fax:203-377-4337
Is Sole Proprietor?:No
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT1193156FX1100X, 156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician
No156FX1100XEye and Vision Services ProvidersTechnician/TechnologistOphthalmic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT1114438652Medicaid