Basic Information
| Provider Information | |||||||||
| NPI: | 1285670513 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | JUSTIN | ||||||||
| MiddleName: | WAYNE | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 S ARLINGTON MILL DR | ||||||||
| Address2: | 916 | ||||||||
| City: | ARLINGTON | ||||||||
| State: | VA | ||||||||
| PostalCode: | 22206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5716436254 | ||||||||
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| Practice Location | |||||||||
| Address1: | STERLING MEDICAL ASSOCIATES | ||||||||
| Address2: | 411 OAK ST | ||||||||
| City: | CINCINNATI | ||||||||
| State: | OH | ||||||||
| PostalCode: | 45219 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5139841800 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/22/2006 | ||||||||
| LastUpdateDate: | 07/08/2007 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 0618001231 | VA | Y | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 9237640 | 05 | VA | MEDICAID |