Provider Demographics
NPI:1285745604
Name:LEE, CHANG SOO DANIEL (OD)
Entity type:Individual
Prefix:DR
First Name:CHANG SOO
Middle Name:DANIEL
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:700 LAFAYETTE RD
Mailing Address - Street 2:
Mailing Address - City:SEABROOK
Mailing Address - State:NH
Mailing Address - Zip Code:03874-6202
Mailing Address - Country:US
Mailing Address - Phone:603-474-1681
Mailing Address - Fax:603-474-0695
Practice Address - Street 1:700 LAFAYETTE RD
Practice Address - Street 2:UNIT 1
Practice Address - City:SEABROOK
Practice Address - State:NH
Practice Address - Zip Code:03874-6202
Practice Address - Country:US
Practice Address - Phone:603-474-1681
Practice Address - Fax:603-474-0695
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-31
Last Update Date:2016-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH0728152W00000X
MA4207152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
7572613OtherAETNA
8966242/67520OtherCIGNA HEALTHCARE
NHNH30852529Medicaid
904088OtherBLOCK VISION
CH1452123OtherCLARITY VISION
18326OtherSPECTERA
27509OtherMEDICAL EYE SERVICE
NH09Y004672NH01OtherBLUE CROSS BLUE SHIELD
207444OtherCOLE VISION
MAAA49702OtherHARVARD PILGRIM
23210OtherAVESIS
MA0712159Medicaid
300042OtherNATIONAL VISION ADM
48514OtherDAVIS VISION
MAAA49702OtherHARVARD PILGRIM
18326OtherSPECTERA