Provider Demographics
NPI:1982917209
Name:PETERSEN, LISA R (OD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:PETERSEN
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:R
Other - Last Name:CRAVEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:OD
Mailing Address - Street 1:10350 E DAKOTA AVE
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80247-1314
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:280 EXEMPLA CIR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-3370
Practice Address - Country:US
Practice Address - Phone:303-338-4545
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-15
Last Update Date:2021-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO2798152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO022563OtherKAISER COMMERCIAL NUMBER
CO21351058Medicaid
CO022563OtherKAISER COMMERCIAL NUMBER