Provider Demographics
NPI:1427091677
Name:LEE, RANDOLPH D (OD)
Entity type:Individual
Prefix:DR
First Name:RANDOLPH
Middle Name:D
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 1:700 N RAYMOND ST
Mailing Address - Street 2:
Mailing Address - City:BOISE
Mailing Address - State:ID
Mailing Address - Zip Code:83704-9261
Mailing Address - Country:US
Mailing Address - Phone:208-375-3871
Mailing Address - Fax:208-321-1765
Practice Address - Street 1:700 N RAYMOND ST
Practice Address - Street 2:
Practice Address - City:BOISE
Practice Address - State:ID
Practice Address - Zip Code:83704-9261
Practice Address - Country:US
Practice Address - Phone:208-375-3871
Practice Address - Fax:208-321-1765
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-14
Last Update Date:2008-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP 591152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IDU08443Medicare UPIN