Provider Demographics
NPI:1134341944
Name:FONTAINE, LISA (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:FONTAINE
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 1:8050 JOVENITA CANYON ROAD
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90046
Mailing Address - Country:US
Mailing Address - Phone:562-716-1870
Mailing Address - Fax:
Practice Address - Street 1:145 W. HILLCREST DR.
Practice Address - Street 2:
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360
Practice Address - Country:US
Practice Address - Phone:805-496-9059
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10988T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist