Provider Demographics
NPI:1144313552
Name:LEE, DERRON TIMOTHY (OD)
Entity type:Individual
Prefix:
First Name:DERRON
Middle Name:TIMOTHY
Last Name:LEE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2321 W MARCH LN STE A
Mailing Address - Street 2:
Mailing Address - City:STOCKTON
Mailing Address - State:CA
Mailing Address - Zip Code:95207-5265
Mailing Address - Country:US
Mailing Address - Phone:209-986-1880
Mailing Address - Fax:209-957-8077
Practice Address - Street 1:2321 W MARCH LN
Practice Address - Street 2:
Practice Address - City:STOCKTON
Practice Address - State:CA
Practice Address - Zip Code:95207-5261
Practice Address - Country:US
Practice Address - Phone:209-986-1880
Practice Address - Fax:209-957-8077
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-30
Last Update Date:2024-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12387T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA11620OtherMESC
CACA2387OtherEYEMED
CAV02414Medicare UPIN