Provider Demographics
NPI:1609869262
Name:KOLLIS-YOUNG, LISA M (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:KOLLIS-YOUNG
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:KOLLIS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:OD
Mailing Address - Street 1:5129 S WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:SIOUX FALLS
Mailing Address - State:SD
Mailing Address - Zip Code:57108
Mailing Address - Country:US
Mailing Address - Phone:605-332-2231
Mailing Address - Fax:
Practice Address - Street 1:5129 S WESTERN AVE
Practice Address - Street 2:
Practice Address - City:SIOUX FALLS
Practice Address - State:SD
Practice Address - Zip Code:57108
Practice Address - Country:US
Practice Address - Phone:605-332-2231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-29
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SD540152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SD9203043Medicaid
SD9203043Medicaid
SD6819Medicare PIN