MEDICARE: DR. LEE CORNFORTH O. D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	1703	WA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	1703	OTHER	WA	O.D. LICENSE NUMBER

General Provider Information

NPI Number	:	1104827203
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LEE CORNFORTH O. D.

Provider Business Mailing Address
First Line	:	504 W BARNETT CIR
Second Line	:
City	:	OCEANSIDE
State	:	CA
Zip	:	92054-8304
Country	:	US
Telephone Number	:	760-725-1307
Fax Number	:	760-725-1135

Provider Business Practice Location Address
First Line	:	NAVHOSP CAMP PENDLETON
Second Line	:
City	:	CAMP PENDLETON
State	:	CA
Zip	:	92055-5191
Country	:	US
Telephone Number	:	760-725-1307
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	08/10/2005
Last Update Date	:	07/08/2007

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