Provider Demographics
NPI:1790820454
Name:MALTZ, LISA (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:MALTZ
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 1:123 LAUREL LN
Mailing Address - Street 2:
Mailing Address - City:LAWRENCE
Mailing Address - State:NY
Mailing Address - Zip Code:11559-1421
Mailing Address - Country:US
Mailing Address - Phone:516-371-2523
Mailing Address - Fax:
Practice Address - Street 1:123 LAUREL LN
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:NY
Practice Address - Zip Code:11559-1421
Practice Address - Country:US
Practice Address - Phone:516-371-2523
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYT005589152W00000X
NJ27OA00576200152W00000X
CT002409152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYU54932Medicare UPIN
NYC00321Medicare ID - Type Unspecified