MEDICARE: DR. JOHN T LEE OD

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	152WC0802X	Corneal and Contact Management Optometrist	OD396	TN

Medicare Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	410009154	OTHER	TN	MEDICARE RAILROAD

General Provider Information

NPI Number	:	1407859853
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. JOHN T LEE OD

Provider Business Mailing Address
First Line	:	5118 PARK AVE
Second Line	:	STE 101
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5710
Country	:	US
Telephone Number	:	901-683-4529
Fax Number	:	901-767-4404

Provider Business Practice Location Address
First Line	:	5118 PARK AVE
Second Line	:	STE 101
City	:	MEMPHIS
State	:	TN
Zip	:	38117-5710
Country	:	US
Telephone Number	:	901-683-4529
Fax Number	:	901-767-4404

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

Provider Enumeration Date	:	05/31/2005
Last Update Date	:	03/03/2008

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