Provider Demographics
NPI:1033288022
Name:BURAKS, LISA ANN (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:ANN
Last Name:BURAKS
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 1:10 WEATHERWOOD LN
Mailing Address - Street 2:
Mailing Address - City:RADNOR
Mailing Address - State:PA
Mailing Address - Zip Code:19087-2724
Mailing Address - Country:US
Mailing Address - Phone:215-530-3112
Mailing Address - Fax:215-755-6561
Practice Address - Street 1:1601 S COLUMBUS BLVD
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19148-1402
Practice Address - Country:US
Practice Address - Phone:215-389-5814
Practice Address - Fax:215-755-6561
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-06
Last Update Date:2011-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000739152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0015391140003Medicaid
PABU793030Medicare ID - Type Unspecified
PABU793030Medicare PIN
PA0015391140003Medicaid