Provider Demographics
NPI:1871518209
Name:LEE, CHARISSA KEI (OD)
Entity type:Individual
Prefix:DR
First Name:CHARISSA
Middle Name:KEI
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 1:3971 IRVINE BLVD STE 110
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92602-2483
Mailing Address - Country:US
Mailing Address - Phone:714-505-0555
Mailing Address - Fax:
Practice Address - Street 1:3971 IRVINE BLVD STE 110
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92602-2483
Practice Address - Country:US
Practice Address - Phone:714-505-0555
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2008-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12261T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA3741536Medicaid
CA3741536Medicaid
CAV99001Medicare UPIN