Healthcare Provider Details

I. General information

NPI: 1316732365
Provider Name (Legal Business Name): JUSTIN DANIEL LEE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2025
Last Update Date: 06/26/2026
Certification Date: 06/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2116 TIDEWATER CIR
COSTA MESA CA
92627-3955
US

IV. Provider business mailing address

2116 TIDEWATER CIR
COSTA MESA CA
92627-3955
US

V. Phone/Fax

Practice location:
  • Phone: 909-952-0989
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number36233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: