Provider Demographics
NPI:1518936947
Name:BENHAM, LISA (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BENHAM
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 1:2791 GREEN RIVER RD
Mailing Address - Street 2:SUITE 106
Mailing Address - City:CORONA
Mailing Address - State:CA
Mailing Address - Zip Code:92882-7426
Mailing Address - Country:US
Mailing Address - Phone:951-736-2020
Mailing Address - Fax:951-736-2002
Practice Address - Street 1:2791 GREEN RIVER RD
Practice Address - Street 2:SUITE 106
Practice Address - City:CORONA
Practice Address - State:CA
Practice Address - Zip Code:92882-7426
Practice Address - Country:US
Practice Address - Phone:951-736-2020
Practice Address - Fax:951-736-2002
Is Sole Proprietor?:No
Enumeration Date:2006-03-16
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9202T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CASD0092020Medicaid
CASD0092020Medicaid
CAU09124Medicare UPIN
CASD0092020Medicaid