Provider Demographics
NPI:1063517399
Name:LEE, JOHN PATRICK (OD)
Entity type:Individual
Prefix:DR
First Name:JOHN
Middle Name:PATRICK
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 1:110 BROAD ST N
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:WI
Mailing Address - Zip Code:54021-1702
Mailing Address - Country:US
Mailing Address - Phone:715-262-1112
Mailing Address - Fax:715-262-1112
Practice Address - Street 1:110 BROAD ST N
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:WI
Practice Address - Zip Code:54021-1702
Practice Address - Country:US
Practice Address - Phone:715-262-1112
Practice Address - Fax:715-262-1112
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI2763-035152W00000X
MN2745152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI38618900Medicaid
WI47258Medicare ID - Type Unspecified
WIU90683Medicare UPIN