Provider Demographics
NPI:1578780250
Name:DECLEMENTE, LISA A (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:DECLEMENTE
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 1:10 SHERIDAN SQ
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10014-6824
Mailing Address - Country:US
Mailing Address - Phone:212-242-6592
Mailing Address - Fax:212-691-3262
Practice Address - Street 1:10 SHERIDAN SQ
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10014-6824
Practice Address - Country:US
Practice Address - Phone:212-242-6592
Practice Address - Fax:212-691-3262
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2012-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY006687152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU98379Medicare UPIN