Basic Information
Provider Information
NPI: 1033559745
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: LEE
FirstName: JI YUN
MiddleName:  
NamePrefix: DR.
NameSuffix:  
Credential: O.D
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 14420 38TH AVE APT L4
Address2:  
City: FLUSHING
State: NY
PostalCode: 113545920
CountryCode: US
TelephoneNumber: 6462479047
FaxNumber:  
Practice Location
Address1: 1710 PITKIN AVE
Address2:  
City: BROOKLYN
State: NY
PostalCode: 112126602
CountryCode: US
TelephoneNumber: 7183425500
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/26/2013
LastUpdateDate: 06/26/2013
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
152W00000XTUV008018-1NYY Eye and Vision Services ProvidersOptometrist 

No ID Information.


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