1407830029 NPI number — DR. AMY MICHELLE LEE O.D.

Table of content: DR. AMY MICHELLE LEE O.D. (NPI 1407830029)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1407830029 NPI number — DR. AMY MICHELLE LEE O.D.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
AMY
Provider Middle Name:
MICHELLE
Provider Name Prefix Text:
DR.
Provider Name Suffix Text:
Provider Credential Text:
O.D.
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
LEE
Provider Other First Name:
AMY
Provider Other Middle Name:
MICHELLE
Provider Other Name Prefix Text:
DR.
Provider Other Name Suffix Text:
Provider Other Credential Text:
O.D.
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1407830029
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/18/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3570 S VAL VISTA DR
Provider Second Line Business Mailing Address:
SUITE R104
Provider Business Mailing Address City Name:
GILBERT
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85297-7326
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
480-899-2381
Provider Business Mailing Address Fax Number:
480-899-1039

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3570 S VAL VISTA DR
Provider Second Line Business Practice Location Address:
SUITE R104
Provider Business Practice Location Address City Name:
GILBERT
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85297-7326
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
480-899-2381
Provider Business Practice Location Address Fax Number:
480-899-1039
Provider Enumeration Date:
12/06/2005

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  1371 , registered in the state of AZ ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 2177937 . This is a "MEDICARE" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".