Provider Demographics
NPI:1437324878
Name:LISA STAFFORD, OD PC
Entity Type:Organization
Organization Name:LISA STAFFORD, OD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:STAFFORD
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:765-659-2020
Mailing Address - Street 1:2070 S STATE ROAD 39
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-7655
Mailing Address - Country:US
Mailing Address - Phone:765-659-2020
Mailing Address - Fax:765-654-4668
Practice Address - Street 1:2070 S STATE ROAD 39
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-7655
Practice Address - Country:US
Practice Address - Phone:765-659-2020
Practice Address - Fax:765-654-4668
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-27
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN4534700001Medicare NSC
INDO7309Medicare PIN
INU64171Medicare UPIN