Provider Demographics
NPI:1871572453
Name:LEE, AMANDA K (OD)
Entity type:Individual
Prefix:DR
First Name:AMANDA
Middle Name:K
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:PO BOX 50997
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29579-0017
Mailing Address - Country:US
Mailing Address - Phone:843-903-0949
Mailing Address - Fax:843-903-1101
Practice Address - Street 1:109 FINNEGAN CT
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29579-4205
Practice Address - Country:US
Practice Address - Phone:843-903-0949
Practice Address - Fax:843-903-1101
Is Sole Proprietor?:No
Enumeration Date:2006-01-12
Last Update Date:2012-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1800152W00000X
SC1644152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093HGMedicaid
NC22-00212OtherUNITED HEALTHCARE NUMBER
NC093HGOtherBCBS NUMBER
NC89093HGMedicaid
NC2471874Medicare ID - Type UnspecifiedAFEC MEDICARE NUMBER
NCU74082Medicare UPIN