Provider Demographics
NPI:1275629693
Name:LIS, DIANE MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:DIANE
Middle Name:MARIE
Last Name:LIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:1904 MIDWEST CLUB PKWY
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-2525
Mailing Address - Country:US
Mailing Address - Phone:630-323-8111
Mailing Address - Fax:630-323-8171
Practice Address - Street 1:801 MEACHAM RD
Practice Address - Street 2:
Practice Address - City:ELK GROVE VILLAGE
Practice Address - State:IL
Practice Address - Zip Code:60007-3073
Practice Address - Country:US
Practice Address - Phone:847-584-7090
Practice Address - Fax:847-584-7092
Is Sole Proprietor?:No
Enumeration Date:2006-10-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL632070Medicare ID - Type UnspecifiedPROVIDER NUMBER
ILU08660Medicare UPIN