Provider Demographics
NPI:1043207558
Name:AHUACTZIN, LISA (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:AHUACTZIN
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 1:220 N MCKEMY AVE
Mailing Address - Street 2:
Mailing Address - City:CHANDLER
Mailing Address - State:AZ
Mailing Address - Zip Code:85226-2654
Mailing Address - Country:US
Mailing Address - Phone:480-961-1865
Mailing Address - Fax:480-961-4605
Practice Address - Street 1:3788 S 16TH AVE
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-6079
Practice Address - Country:US
Practice Address - Phone:520-388-9741
Practice Address - Fax:520-388-9750
Is Sole Proprietor?:No
Enumeration Date:2005-09-29
Last Update Date:2014-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ996152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZZ162758Medicare PIN
AZU72758Medicare UPIN
AZZ162075Medicare PIN