Provider Demographics
NPI:1518903426
Name:DRAKE, LISA DANIELLE (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DANIELLE
Last Name:DRAKE
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:PO BOX 5721
Mailing Address - Street 2:ATTN ADMINISTRATOR
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29250
Mailing Address - Country:US
Mailing Address - Phone:803-779-2273
Mailing Address - Fax:803-799-0854
Practice Address - Street 1:1600 TAYLOR STREET
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29201
Practice Address - Country:US
Practice Address - Phone:803-779-7783
Practice Address - Fax:803-217-3571
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1018152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCD10183Medicaid
SC20047639OtherSELECT HEALTH OF SC
SCD10183Medicaid