Provider Demographics
NPI:1891719845
Name:DUDLEY, LISA CAROL (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CAROL
Last Name:DUDLEY
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 1:3515 SELWYN AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-3501
Mailing Address - Country:US
Mailing Address - Phone:704-521-2719
Mailing Address - Fax:704-567-0238
Practice Address - Street 1:3061 N SHARON AMITY RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28205-6600
Practice Address - Country:US
Practice Address - Phone:704-567-6755
Practice Address - Fax:704-567-0238
Is Sole Proprietor?:No
Enumeration Date:2006-07-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1924152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC89093R5Medicaid
NCU99011Medicare UPIN
NC89093R5Medicaid