Provider Demographics
NPI:1720646193
Name:LEE, COLIN (OD)
Entity Type:Individual
Prefix:DR
First Name:COLIN
Middle Name:
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 1:1223 W 33RD PL
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60608-6459
Mailing Address - Country:US
Mailing Address - Phone:312-927-3741
Mailing Address - Fax:
Practice Address - Street 1:W180N8000 TOWN HALL RD
Practice Address - Street 2:
Practice Address - City:MENOMONEE FALLS
Practice Address - State:WI
Practice Address - Zip Code:53051-4002
Practice Address - Country:US
Practice Address - Phone:262-532-3271
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-05-31
Last Update Date:2023-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011310152W00000X
WI3879-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3879-35OtherLICENSED OPTOMETRIST
IL046.011310OtherLICENSED OPTOMETRIST