Provider Demographics
NPI:1851324123
Name:PRADILLO, LISA R (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:PRADILLO
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 1:1501 DEREK DR
Mailing Address - Street 2:
Mailing Address - City:HAMMOND
Mailing Address - State:LA
Mailing Address - Zip Code:70403-5745
Mailing Address - Country:US
Mailing Address - Phone:985-345-0607
Mailing Address - Fax:985-345-0490
Practice Address - Street 1:1501 DEREK DR
Practice Address - Street 2:
Practice Address - City:HAMMOND
Practice Address - State:LA
Practice Address - Zip Code:70403-5745
Practice Address - Country:US
Practice Address - Phone:985-345-0607
Practice Address - Fax:985-345-0490
Is Sole Proprietor?:No
Enumeration Date:2006-07-09
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA1415-555T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
LAG28579Medicare UPIN