Provider Demographics
NPI:1780724138
Name:NUTT, LISA M (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:NUTT
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 1:6000 N OAK TRFY STE 101
Mailing Address - Street 2:
Mailing Address - City:GLADSTONE
Mailing Address - State:MO
Mailing Address - Zip Code:64118-5176
Mailing Address - Country:US
Mailing Address - Phone:816-454-1030
Mailing Address - Fax:
Practice Address - Street 1:6000 N OAK TRFY STE 101
Practice Address - Street 2:
Practice Address - City:GLADSTONE
Practice Address - State:MO
Practice Address - Zip Code:64118-5176
Practice Address - Country:US
Practice Address - Phone:816-454-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-07
Last Update Date:2015-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2002014342152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO410039208OtherRAILROAD MEDICARE
MO30976011OtherBLUE CROSS
MO315972109Medicaid
MO431447951OtherTAX ID
MOA65B931Medicare ID - Type Unspecified
MO410039208OtherRAILROAD MEDICARE
MO431447951OtherTAX ID