Provider Demographics
NPI:1093938318
Name:JONES, LISA FOUGERE (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FOUGERE
Last Name:JONES
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 1:150 NE 20TH ST
Mailing Address - Street 2:INSIDE VISTA OPTICAL
Mailing Address - City:NEWPORT
Mailing Address - State:OR
Mailing Address - Zip Code:97365-1851
Mailing Address - Country:US
Mailing Address - Phone:541-265-4201
Mailing Address - Fax:541-265-4202
Practice Address - Street 1:150 NE 20TH ST
Practice Address - Street 2:INSIDE VISTA OPTICAL
Practice Address - City:NEWPORT
Practice Address - State:OR
Practice Address - Zip Code:97365-1851
Practice Address - Country:US
Practice Address - Phone:541-265-4201
Practice Address - Fax:541-265-4202
Is Sole Proprietor?:No
Enumeration Date:2007-04-11
Last Update Date:2015-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR3348AT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA2032175Medicaid