Provider Demographics
NPI:1710621842
Name:HOLDEN BISTA, PAYTON MARIE (OD)
Entity type:Individual
Prefix:MRS
First Name:PAYTON
Middle Name:MARIE
Last Name:HOLDEN BISTA
Suffix:
Gender:F
Credentials:OD
Other - Prefix:MS
Other - First Name:PAYTON
Other - Middle Name:MARIE
Other - Last Name:HOLDEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:3325 ANDERS LANE
Mailing Address - Street 2:
Mailing Address - City:BROOKFIELD
Mailing Address - State:WI
Mailing Address - Zip Code:53005-2804
Mailing Address - Country:US
Mailing Address - Phone:810-969-2280
Mailing Address - Fax:414-453-1330
Practice Address - Street 1:7511 HARWOOD AVE
Practice Address - Street 2:
Practice Address - City:WAOWATOSA
Practice Address - State:WI
Practice Address - Zip Code:53213-2606
Practice Address - Country:US
Practice Address - Phone:414-453-1300
Practice Address - Fax:414-453-1330
Is Sole Proprietor?:No
Enumeration Date:2022-04-25
Last Update Date:2025-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046011619152W00000X
WI3869-35152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist