Provider Demographics
NPI:1548370828
Name:DODGE, LEE EDWARD IV (OD)
Entity type:Individual
Prefix:DR
First Name:LEE
Middle Name:EDWARD
Last Name:DODGE
Suffix:IV
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 1:14429 1/2 VENTURA BLVD
Mailing Address - Street 2:
Mailing Address - City:SHERMAN OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91423
Mailing Address - Country:US
Mailing Address - Phone:818-783-8750
Mailing Address - Fax:
Practice Address - Street 1:14429 1-2 VENTURA BLVD
Practice Address - Street 2:
Practice Address - City:SHERMAN OAKS
Practice Address - State:CA
Practice Address - Zip Code:91423
Practice Address - Country:US
Practice Address - Phone:818-783-8750
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA12800T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist