Provider Demographics
NPI:1982704979
Name:LEE, LEANNE (OD)
Entity Type:Individual
Prefix:
First Name:LEANNE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:2433 BROADRIDGE WAY
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95209-1246
Mailing Address - Country:US
Mailing Address - Phone:209-477-3888
Mailing Address - Fax:
Practice Address - Street 1:2321 W MARCH LN
Practice Address - Street 2:STE A
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5261
Practice Address - Country:US
Practice Address - Phone:209-957-8000
Practice Address - Fax:209-957-8077
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-22
Last Update Date:2016-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12388T152WP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WP0200XEye and Vision Services ProvidersOptometristPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ04208ZMedicare PIN
CAV02468Medicare UPIN