Provider Demographics
NPI:1154526358
Name:LEE, IVAN (OD)
Entity type:Individual
Prefix:DR
First Name:IVAN
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 1:25 AGATHA DR
Mailing Address - Street 2:
Mailing Address - City:EDISON
Mailing Address - State:NJ
Mailing Address - Zip Code:08817-2224
Mailing Address - Country:US
Mailing Address - Phone:908-507-1368
Mailing Address - Fax:
Practice Address - Street 1:1777 KUSER RD
Practice Address - Street 2:
Practice Address - City:HAMILTON SQUARE
Practice Address - State:NJ
Practice Address - Zip Code:08690-3703
Practice Address - Country:US
Practice Address - Phone:609-581-5755
Practice Address - Fax:609-581-7055
Is Sole Proprietor?:No
Enumeration Date:2007-06-18
Last Update Date:2007-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ270A00556300152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJU72700Medicare UPIN
NJ019953BEYMedicare PIN
NJ019953P1GMedicare PIN
NJ019953P1HMedicare PIN
NJT72700Medicare UPIN