Provider Demographics
NPI:1104833615
Name:MOFFITT, LISA (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:MOFFITT
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:30 TRINITY POINT DR
Mailing Address - Street 2:WALMART VISION CENTER
Mailing Address - City:WASHINGTON
Mailing Address - State:PA
Mailing Address - Zip Code:15301-2974
Mailing Address - Country:US
Mailing Address - Phone:724-229-7769
Mailing Address - Fax:724-229-7792
Practice Address - Street 1:16086 CONNEAUT LAKE RD
Practice Address - Street 2:WALMART VISION CENTER
Practice Address - City:MEADVILLE
Practice Address - State:PA
Practice Address - Zip Code:16335-3884
Practice Address - Country:US
Practice Address - Phone:816-337-4426
Practice Address - Fax:814-337-4320
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2016-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPA0EG000769152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0000027186OtherMEDICARE
376852OtherBCBS
PA001746361 0003OtherPA DEPT OF HUMAN SERVICES
0017463610003OtherPROMISE WELFARE
52269OtherDAVIS
376852OtherBCBS