Provider Demographics
NPI:1629074620
Name:DURHAM, LISA (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:DURHAM
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:SCHELLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:40 E NORTH ST
Mailing Address - Street 2:
Mailing Address - City:EUREKA
Mailing Address - State:MO
Mailing Address - Zip Code:63025-1205
Mailing Address - Country:US
Mailing Address - Phone:636-200-4393
Mailing Address - Fax:636-938-2650
Practice Address - Street 1:54 THE LEGENDS PKWY STE 151
Practice Address - Street 2:
Practice Address - City:EUREKA
Practice Address - State:MO
Practice Address - Zip Code:63025-3803
Practice Address - Country:US
Practice Address - Phone:636-938-7010
Practice Address - Fax:636-938-7141
Is Sole Proprietor?:No
Enumeration Date:2005-06-23
Last Update Date:2014-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2004017331152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO318454717Medicaid
MO318454709Medicaid
V02658Medicare UPIN
MO318454709Medicaid
MOMA5227037Medicare UPIN
MO318454717Medicaid