Provider Demographics
NPI:1720076375
Name:LAGASSA, LISA RENEE (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:LAGASSA
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 1:42260 DHARTE CT
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48038-6433
Mailing Address - Country:US
Mailing Address - Phone:586-801-4309
Mailing Address - Fax:313-881-9380
Practice Address - Street 1:20525 MACK AVE
Practice Address - Street 2:
Practice Address - City:GROSSE POINTE WOODS
Practice Address - State:MI
Practice Address - Zip Code:48236-1655
Practice Address - Country:US
Practice Address - Phone:313-881-6622
Practice Address - Fax:313-881-9380
Is Sole Proprietor?:No
Enumeration Date:2005-10-07
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4901003663152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI204683OtherCOLE PROVIDER #
MI90-0-H2-2311-0OtherBCBS #
MI90-0-H2-2311-0OtherBCBS #
MION55850001Medicare ID - Type UnspecifiedMEDICARE #