Provider Demographics
NPI:1669400172
Name:LEE, MARK ROBERT (OD)
Entity type:Individual
Prefix:
First Name:MARK
Middle Name:ROBERT
Last Name:LEE
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 1:8937 W SAHARA AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89117-5883
Mailing Address - Country:US
Mailing Address - Phone:702-254-3558
Mailing Address - Fax:702-876-8160
Practice Address - Street 1:8937 W SAHARA AVE
Practice Address - Street 2:SUITE A
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89117-5883
Practice Address - Country:US
Practice Address - Phone:702-254-3558
Practice Address - Fax:702-876-8160
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2018-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV0390152W00000X
OR2785T152W00000X
WAOD00003586152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV100503029Medicaid
NVV38976Medicare PIN
NV100503029Medicaid