Provider Demographics
NPI:1700254661
Name:LEE BOTTEM DO PLC
Entity Type:Organization
Organization Name:LEE BOTTEM DO PLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRACTICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:AISHA
Authorized Official - Middle Name:D
Authorized Official - Last Name:HAIR
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, OMT
Authorized Official - Phone:918-994-4104
Mailing Address - Street 1:3920 E 91ST ST
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74137-3602
Mailing Address - Country:US
Mailing Address - Phone:918-994-4104
Mailing Address - Fax:918-994-4106
Practice Address - Street 1:3131 MILITARY BLVD
Practice Address - Street 2:
Practice Address - City:MUSKOGEE
Practice Address - State:OK
Practice Address - Zip Code:74401-2290
Practice Address - Country:US
Practice Address - Phone:918-994-4104
Practice Address - Fax:918-994-4106
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-09
Last Update Date:2015-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4175207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmologyGroup - Single Specialty