Provider Demographics
NPI:1922077189
Name:CHILES, LISA B (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:B
Last Name:CHILES
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 1:1235 E HARMONT DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85020-3864
Mailing Address - Country:US
Mailing Address - Phone:602-331-1470
Mailing Address - Fax:602-678-5819
Practice Address - Street 1:1235 E HARMONT DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85020-3864
Practice Address - Country:US
Practice Address - Phone:602-331-1470
Practice Address - Fax:602-678-5819
Is Sole Proprietor?:No
Enumeration Date:2006-03-17
Last Update Date:2024-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001146152W00000X
VA1575152WL0500X
AZ1575152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
No152WL0500XEye and Vision Services ProvidersOptometristLow Vision Rehabilitation
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010073685Medicaid
VAU86238Medicare UPIN
AZZ162810Medicare PIN
VA010073685Medicaid
VA005039C83Medicare ID - Type Unspecified