Provider Demographics
NPI:1861487613
Name:WILSON, LISA M (OD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WILSON
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 1:41637 MARGARITA RD
Mailing Address - Street 2:STE 100
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92591-2990
Mailing Address - Country:US
Mailing Address - Phone:951-296-9300
Mailing Address - Fax:
Practice Address - Street 1:41637 MARGARITA RD
Practice Address - Street 2:STE 100
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-2990
Practice Address - Country:US
Practice Address - Phone:951-296-9300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-09-19
Last Update Date:2013-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA13706152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAW17591Medicare PIN