Provider Demographics
NPI:1528012077
Name:NIRODE, LISA L (OD)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:L
Last Name:NIRODE
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 1:28370 KENSINGTON LN
Mailing Address - Street 2:STE A
Mailing Address - City:PERRYSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43551-4180
Mailing Address - Country:US
Mailing Address - Phone:419-865-3866
Mailing Address - Fax:419-865-3451
Practice Address - Street 1:5555 AIRPORT HWY
Practice Address - Street 2:SUITE 110
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43615-7380
Practice Address - Country:US
Practice Address - Phone:419-865-3866
Practice Address - Fax:419-865-3451
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2017-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH3684 T579152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0520798Medicaid
OHNI0825061Medicare ID - Type Unspecified
OH0520798Medicaid