Provider Demographics
NPI:1548396294
Name:SLADEK, LISA MARIE (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:SLADEK
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:KOMMER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:55 CAMPAU AVE NW
Mailing Address - Street 2:SUITE 10
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-2642
Mailing Address - Country:US
Mailing Address - Phone:616-459-7380
Mailing Address - Fax:616-459-5752
Practice Address - Street 1:55 CAMPAU AVE NW
Practice Address - Street 2:SUITE 10
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-2642
Practice Address - Country:US
Practice Address - Phone:616-459-7380
Practice Address - Fax:616-459-5752
Is Sole Proprietor?:No
Enumeration Date:2007-02-26
Last Update Date:2010-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003881152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI900D114630OtherBLUE CROSS BLUE SHIELD
MI900D114630OtherBLUE CROSS BLUE SHIELD
MIU86599Medicare UPIN
MI5277960001Medicare NSC