Provider Demographics
NPI:1356373914
Name:WALLACE-DAVIS, LISA G (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
Last Name:WALLACE-DAVIS
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Other - Credentials:
Mailing Address - Street 1:1134 BIG BETHEL RD
Mailing Address - Street 2:
Mailing Address - City:HAMPTON
Mailing Address - State:VA
Mailing Address - Zip Code:23666-1906
Mailing Address - Country:US
Mailing Address - Phone:757-827-6612
Mailing Address - Fax:757-827-6296
Practice Address - Street 1:1134 BIG BETHEL RD
Practice Address - Street 2:
Practice Address - City:HAMPTON
Practice Address - State:VA
Practice Address - Zip Code:23666-1906
Practice Address - Country:US
Practice Address - Phone:757-827-6612
Practice Address - Fax:757-827-6296
Is Sole Proprietor?:No
Enumeration Date:2006-07-06
Last Update Date:2011-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618000303152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0618000303OtherSTATE LICENSE
VA009232583Medicaid
541786245OtherTAX ID
VA0618000303OtherSTATE LICENSE
VAVV3392A349Medicare PIN