Provider Demographics
NPI:1083774699
Name:CHABOT, LISA (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CHABOT
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 1:248 S FLORISSANT RD
Mailing Address - Street 2:
Mailing Address - City:FERGUSON
Mailing Address - State:MO
Mailing Address - Zip Code:63135-2737
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:248 S FLORISSANT RD
Practice Address - Street 2:
Practice Address - City:FERGUSON
Practice Address - State:MO
Practice Address - Zip Code:63135-2736
Practice Address - Country:US
Practice Address - Phone:314-522-8773
Practice Address - Fax:314-522-0228
Is Sole Proprietor?:No
Enumeration Date:2006-12-12
Last Update Date:2015-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03129152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO316777663Medicaid
MO181457OtherBLUE CROSS BLUE SHIELD
MO410043549Medicare PIN
U45249Medicare UPIN
MO316777663Medicaid
44446001Medicare PIN
MO911804278Medicare PIN