Provider Demographics
NPI:1528117413
Name:LEE, KERRI DAVIDOVE (OD)
Entity type:Individual
Prefix:
First Name:KERRI
Middle Name:DAVIDOVE
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 1:8447 LAUREL CANYON BLVD
Mailing Address - Street 2:
Mailing Address - City:SUN VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91352
Mailing Address - Country:US
Mailing Address - Phone:818-504-2020
Mailing Address - Fax:818-504-2070
Practice Address - Street 1:8447 LAUREL CANYON BLVD
Practice Address - Street 2:
Practice Address - City:SUN VALLEY
Practice Address - State:CA
Practice Address - Zip Code:91352
Practice Address - Country:US
Practice Address - Phone:818-504-2020
Practice Address - Fax:818-504-2070
Is Sole Proprietor?:No
Enumeration Date:2007-01-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT7786TPA152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U37113Medicare UPIN