Provider Demographics
NPI:1366491672
Name:DAVIS, LISA VICTORIA (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:VICTORIA
Last Name:DAVIS
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 1:7530 MOUNTAIN AVE
Mailing Address - Street 2:
Mailing Address - City:MELROSE PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3024
Mailing Address - Country:US
Mailing Address - Phone:215-782-8710
Mailing Address - Fax:215-782-3784
Practice Address - Street 1:101 OLD YORK RD STE 306
Practice Address - Street 2:
Practice Address - City:JENKINTOWN
Practice Address - State:PA
Practice Address - Zip Code:19046-3900
Practice Address - Country:US
Practice Address - Phone:215-376-0306
Practice Address - Fax:215-376-0376
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-06
Last Update Date:2019-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG000695152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU55422Medicare UPIN
PA598134Medicare ID - Type Unspecified