Provider Demographics
NPI:1548210032
Name:THATCH, LISA (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:THATCH
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 1:2698 GRAVOIS RD
Mailing Address - Street 2:
Mailing Address - City:HIGH RIDGE
Mailing Address - State:MO
Mailing Address - Zip Code:63049-2508
Mailing Address - Country:US
Mailing Address - Phone:636-677-1166
Mailing Address - Fax:636-677-1324
Practice Address - Street 1:2698 GRAVOIS RD
Practice Address - Street 2:
Practice Address - City:HIGH RIDGE
Practice Address - State:MO
Practice Address - Zip Code:63049-2508
Practice Address - Country:US
Practice Address - Phone:636-677-1166
Practice Address - Fax:636-677-1324
Is Sole Proprietor?:No
Enumeration Date:2006-05-12
Last Update Date:2019-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046-009535152W00000X
MO2003014792152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP00040122OtherMEDICARE RAILROAD
IL0814870023OtherMEDICARE NSC NUMBER
087817OtherHEALTH ALLIANCE
IL046009535Medicaid
IL9535OtherEYEMED
IL0814870026OtherMEDICARE NSC NUMBER
252039OtherHARMONY HEALTH PLAN
IL0814870010OtherMEDICARE NSC NUMBER
IL0814870026OtherMEDICARE NSC NUMBER
ILU95902Medicare UPIN
ILL99673Medicare PIN