Provider Demographics
NPI:1811127723
Name:LEE, MIRANDA G (OD)
Entity type:Individual
Prefix:
First Name:MIRANDA
Middle Name:G
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2401 US HIGHWAY 22 W
Mailing Address - Street 2:STE P
Mailing Address - City:UNION
Mailing Address - State:NJ
Mailing Address - Zip Code:07083-8519
Mailing Address - Country:US
Mailing Address - Phone:908-378-1821
Mailing Address - Fax:
Practice Address - Street 1:2401 US HIGHWAY 22 W
Practice Address - Street 2:STE P
Practice Address - City:UNION
Practice Address - State:NJ
Practice Address - Zip Code:07083-8519
Practice Address - Country:US
Practice Address - Phone:908-378-1821
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-07-27
Last Update Date:2014-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ1742152W00000X
NY007474152W00000X
NJ27OA00645000152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist