Provider Demographics
NPI:1598879637
Name:MODESTO, LISA MARIA (OD)
Entity Type:Individual
Prefix:MISS
First Name:LISA
Middle Name:MARIA
Last Name:MODESTO
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 1:610 E 20TH ST APT 4E
Mailing Address - Street 2:APT. 4 E
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10009-1403
Mailing Address - Country:US
Mailing Address - Phone:917-843-9639
Mailing Address - Fax:
Practice Address - Street 1:10933 71ST RD
Practice Address - Street 2:SUITE 2 C
Practice Address - City:FOREST HILLS
Practice Address - State:NY
Practice Address - Zip Code:11375-4867
Practice Address - Country:US
Practice Address - Phone:718-261-3366
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-18
Last Update Date:2008-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYTUV007078152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist