Healthcare Provider Details

I. General information

NPI: 1245545102
Provider Name (Legal Business Name): MIRIAM LEE O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/16/2010
Last Update Date: 11/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11915 ATLANTIC AVE
RICHMOND HILL NY
11418-3216
US

IV. Provider business mailing address

184 HARRIS AVE
HEWLETT NY
11557-1319
US

V. Phone/Fax

Practice location:
  • Phone: 718-805-0700
  • Fax:
Mailing address:
  • Phone: 516-374-5662
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number007618
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: