Provider Demographics
NPI:1942907845
Name:POTTS, LISA KAY (LDO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:KAY
Last Name:POTTS
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3465 YORK COMMONS BLVD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-2675
Mailing Address - Country:US
Mailing Address - Phone:937-454-6450
Mailing Address - Fax:937-454-6452
Practice Address - Street 1:3465 YORK COMMONS BLVD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45414-2675
Practice Address - Country:US
Practice Address - Phone:937-454-6450
Practice Address - Fax:937-454-6452
Is Sole Proprietor?:Yes
Enumeration Date:2023-02-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician