Provider Demographics
NPI:1710951330
Name:COPPLE, LISA A (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:A
Last Name:COPPLE
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 1:3725 INGERSOLL AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50312-3410
Mailing Address - Country:US
Mailing Address - Phone:515-279-2020
Mailing Address - Fax:515-255-8002
Practice Address - Street 1:1540 VALLEY WEST DR
Practice Address - Street 2:
Practice Address - City:WEST DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50266-1101
Practice Address - Country:US
Practice Address - Phone:515-223-8666
Practice Address - Fax:515-225-1411
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-13
Last Update Date:2017-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02025152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1102566Medicaid
IA14497OtherBLUE CROSS
U44481Medicare UPIN
IA14497Medicare ID - Type Unspecified