Provider Demographics
NPI:1780346189
Name:LEE, NATHAN (OD)
Entity type:Individual
Prefix:
First Name:NATHAN
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 1:2250 CAMINO DE LA REINA UNIT 6207
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-5519
Mailing Address - Country:US
Mailing Address - Phone:714-675-9225
Mailing Address - Fax:
Practice Address - Street 1:6255 LUSK BLVD STE 100
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92121-3763
Practice Address - Country:US
Practice Address - Phone:858-452-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-10-12
Last Update Date:2021-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA35022152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist