Provider Demographics
NPI:1386779585
Name:LEE, KYLE MINGSANG (OD)
Entity type:Individual
Prefix:DR
First Name:KYLE
Middle Name:MINGSANG
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:9237 LAGUNA LAKE WAY
Mailing Address - Street 2:
Mailing Address - City:ELK GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:95758-4236
Mailing Address - Country:US
Mailing Address - Phone:415-652-2139
Mailing Address - Fax:510-889-1519
Practice Address - Street 1:9237 LAGUNA LAKE WAY
Practice Address - Street 2:
Practice Address - City:ELK GROVE
Practice Address - State:CA
Practice Address - Zip Code:95758-4236
Practice Address - Country:US
Practice Address - Phone:415-652-2139
Practice Address - Fax:510-889-1519
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11013T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0110130Medicare ID - Type UnspecifiedPHYSICIAN I.D. CODE