Healthcare Provider Details

I. General information

NPI: 1134115116
Provider Name (Legal Business Name): JOHN LEE OD
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/23/2005
Last Update Date: 08/26/2026
Certification Date: 08/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 WASHINGTON ST
HANOVER MA
02339-1694
US

IV. Provider business mailing address

1422 WASHINGTON ST
HANOVER MA
02339-1694
US

V. Phone/Fax

Practice location:
  • Phone: 781-826-8393
  • Fax: 781-826-8764
Mailing address:
  • Phone: 781-826-8393
  • Fax: 781-826-8764

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4502
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: