Provider Demographics
NPI:1134503204
Name:KOEPKE, LIZA SMITH (OD)
Entity Type:Individual
Prefix:DR
First Name:LIZA
Middle Name:SMITH
Last Name:KOEPKE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LIZA
Other - Middle Name:STEPHANIE
Other - Last Name:SMITH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:30212 TOMAS
Mailing Address - Street 2:SUITE 170
Mailing Address - City:RANCHO SANTA MARGARITA
Mailing Address - State:CA
Mailing Address - Zip Code:92688-2172
Mailing Address - Country:US
Mailing Address - Phone:949-589-0900
Mailing Address - Fax:949-589-0767
Practice Address - Street 1:30212 TOMAS
Practice Address - Street 2:SUITE 170
Practice Address - City:RANCHO SANTA MARGARITA
Practice Address - State:CA
Practice Address - Zip Code:92688-2172
Practice Address - Country:US
Practice Address - Phone:949-589-0900
Practice Address - Fax:949-589-0767
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-17
Last Update Date:2017-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15362152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist