Provider Demographics
NPI:1790778306
Name:LISLE, JAMES THOMAS (OD)
Entity Type:Individual
Prefix:DR
First Name:JAMES
Middle Name:THOMAS
Last Name:LISLE
Suffix:
Gender:M
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:747 N STATE ST
Mailing Address - Street 2:
Mailing Address - City:NORTH VERNON
Mailing Address - State:IN
Mailing Address - Zip Code:47265-1044
Mailing Address - Country:US
Mailing Address - Phone:812-352-6600
Mailing Address - Fax:812-352-6600
Practice Address - Street 1:747 N STATE ST
Practice Address - Street 2:
Practice Address - City:NORTH VERNON
Practice Address - State:IN
Practice Address - Zip Code:47265-1044
Practice Address - Country:US
Practice Address - Phone:812-346-8500
Practice Address - Fax:812-352-8308
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-30
Last Update Date:2016-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002981A152W00000X
KY1415DT152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200335310AMedicaid
KY924288OtherBLOCK VISION
KY7700115400OtherKYHEALTH CHOICES
IN200347550Medicaid
IN200347550Medicaid
KY924288OtherBLOCK VISION
INU85566Medicare UPIN
IN4331560001Medicare NSC