Provider Demographics
NPI:1598795908
Name:CHAN-O'CONNELL, LISA (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CHAN-O'CONNELL
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 1:800 POLY PL
Mailing Address - Street 2:BROOKLYN VA
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11209-7104
Mailing Address - Country:US
Mailing Address - Phone:718-836-6600
Mailing Address - Fax:
Practice Address - Street 1:800 POLY PL
Practice Address - Street 2:BROOKLYN VA
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11209-7104
Practice Address - Country:US
Practice Address - Phone:718-836-6600
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-03
Last Update Date:2016-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV006091152W00000X, 152WL0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU80877Medicare UPIN
NYLCOC656210Medicare ID - Type UnspecifiedEMPIRE MEDICARE PROVIDER