Provider Demographics
NPI:1174040737
Name:PREJEAN, LISA MICHELLE (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:PREJEAN
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 1:531 WESTBURY LN
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-4465
Mailing Address - Country:US
Mailing Address - Phone:979-236-8838
Mailing Address - Fax:
Practice Address - Street 1:2910 MARKET LOOP
Practice Address - Street 2:
Practice Address - City:TEMPLE
Practice Address - State:TX
Practice Address - Zip Code:76502-1855
Practice Address - Country:US
Practice Address - Phone:254-778-6165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-08-24
Last Update Date:2017-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALR-258152W00000X
TX9045TG152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist