Provider Demographics
NPI:1306109897
Name:LEE, ELLEN (OD)
Entity type:Individual
Prefix:
First Name:ELLEN
Middle Name:
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 1:3710 SW VETERANS HOSPITAL RD
Mailing Address - Street 2:R&D 14
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97239-2964
Mailing Address - Country:US
Mailing Address - Phone:503-220-8262
Mailing Address - Fax:
Practice Address - Street 1:3710 SW VETERANS HOSPITAL RD
Practice Address - Street 2:R&D 14
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97239-2964
Practice Address - Country:US
Practice Address - Phone:503-220-8262
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-19
Last Update Date:2013-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10621152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist