Provider Demographics
NPI:1396787214
Name:LEE, SYLVIA KANG (OD, PHD)
Entity type:Individual
Prefix:DR
First Name:SYLVIA
Middle Name:KANG
Last Name:LEE
Suffix:
Gender:F
Credentials:OD, PHD
Other - Prefix:DR
Other - First Name:SYLVIA
Other - Middle Name:SUNJU
Other - Last Name:KANG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD, PHD
Mailing Address - Street 1:211B EL CAMINO REAL
Mailing Address - Street 2:
Mailing Address - City:GREENFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93927-5125
Mailing Address - Country:US
Mailing Address - Phone:831-724-1063
Mailing Address - Fax:931-724-1067
Practice Address - Street 1:211B EL CAMINO REAL STE 2
Practice Address - Street 2:
Practice Address - City:GREENFIELD
Practice Address - State:CA
Practice Address - Zip Code:93927-5125
Practice Address - Country:US
Practice Address - Phone:831-674-8131
Practice Address - Fax:831-674-8132
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2019-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006237152W00000X
CAOPT 12225 TPA152W00000X
CA12225152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02182103Medicaid
U83027Medicare UPIN
NYC68691Medicare ID - Type Unspecified