Provider Demographics
NPI:1790867091
Name:WEISS, LISA MICHELLE (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MICHELLE
Last Name:WEISS
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:PO BOX 275
Mailing Address - Street 2:
Mailing Address - City:RANCHO SANTA FE
Mailing Address - State:CA
Mailing Address - Zip Code:92067-0275
Mailing Address - Country:US
Mailing Address - Phone:858-756-3210
Mailing Address - Fax:
Practice Address - Street 1:6037 LA GRANADA STE A
Practice Address - Street 2:
Practice Address - City:RANCHO SANTA FE
Practice Address - State:CA
Practice Address - Zip Code:92067
Practice Address - Country:US
Practice Address - Phone:858-756-3210
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2020-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA11405T152WC0802X, 152WP0200X, 152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
No152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
No152WP0200XEye and Vision Services ProvidersOptometristPediatrics