Provider Demographics
NPI:1104840578
Name:DAVIS, LISA N (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:N
Last Name:DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3316 SILAS CREEK PKWY
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-3011
Mailing Address - Country:US
Mailing Address - Phone:336-765-5350
Mailing Address - Fax:336-765-0769
Practice Address - Street 1:235 HARVEY ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1741
Practice Address - Country:US
Practice Address - Phone:336-842-0952
Practice Address - Fax:336-793-3475
Is Sole Proprietor?:No
Enumeration Date:2006-07-27
Last Update Date:2019-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1285152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7909119Medicaid
NC7909119Medicaid
246629BMedicare ID - Type Unspecified