Provider Demographics
NPI:1609988872
Name:STAFFORD, LISA LYNN (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:LYNN
Last Name:STAFFORD
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 1:2070 S STATE ROAD 39
Mailing Address - Street 2:
Mailing Address - City:FRANKFORT
Mailing Address - State:IN
Mailing Address - Zip Code:46041-7655
Mailing Address - Country:US
Mailing Address - Phone:765-659-2020
Mailing Address - Fax:765-654-4668
Practice Address - Street 1:2070 S STATE ROAD 39
Practice Address - Street 2:
Practice Address - City:FRANKFORT
Practice Address - State:IN
Practice Address - Zip Code:46041-7655
Practice Address - Country:US
Practice Address - Phone:765-659-2020
Practice Address - Fax:765-654-4668
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002840152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000230330OtherBLUE CROSS BLUE SHIELD
IN200107990Medicaid
IN200107990Medicaid
IN191270Medicare ID - Type Unspecified
IN410048062Medicare PIN
IN000000230330OtherBLUE CROSS BLUE SHIELD