Provider Demographics
NPI:1013192350
Name:MCKIM, LISA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:MCKIM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4417 RAPTOR CIR
Mailing Address - Street 2:
Mailing Address - City:TYNDALL AFB
Mailing Address - State:FL
Mailing Address - Zip Code:32403-1063
Mailing Address - Country:US
Mailing Address - Phone:813-777-1415
Mailing Address - Fax:
Practice Address - Street 1:1707 W 23RD ST
Practice Address - Street 2:
Practice Address - City:PANAMA CITY
Practice Address - State:FL
Practice Address - Zip Code:32405-2916
Practice Address - Country:US
Practice Address - Phone:850-769-4747
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-07
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOPC 4506152W00000X, 152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
U71919Medicare UPIN