Healthcare Provider Details

I. General information

NPI: 1891829826
Provider Name (Legal Business Name): LEE W PURDY O.D.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/14/2007
Last Update Date: 02/21/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1334 N 4TH ST STE 101
TOMAHAWK WI
54487-2137
US

IV. Provider business mailing address

1334 N 4TH ST STE 101
TOMAHAWK WI
54487-2137
US

V. Phone/Fax

Practice location:
  • Phone: 715-532-5501
  • Fax: 715-532-5502
Mailing address:
  • Phone: 715-532-5501
  • Fax: 715-532-5502

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number1899
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: