1104833615 NPI number — LISA MOFFITT OD

Table of content: LISA MOFFITT OD (NPI 1104833615)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1104833615 NPI number — LISA MOFFITT OD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MOFFITT
Provider First Name:
LISA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
OD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1104833615
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/01/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
30 TRINITY POINT DR
Provider Second Line Business Mailing Address:
WALMART VISION CENTER
Provider Business Mailing Address City Name:
WASHINGTON
Provider Business Mailing Address State Name:
PA
Provider Business Mailing Address Postal Code:
15301-2974
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
724-229-7769
Provider Business Mailing Address Fax Number:
724-229-7792

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16086 CONNEAUT LAKE RD
Provider Second Line Business Practice Location Address:
WALMART VISION CENTER
Provider Business Practice Location Address City Name:
MEADVILLE
Provider Business Practice Location Address State Name:
PA
Provider Business Practice Location Address Postal Code:
16335-3884
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
816-337-4426
Provider Business Practice Location Address Fax Number:
814-337-4320
Provider Enumeration Date:
08/01/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 152W00000X , with the licence number:  PA0EG000769 , registered in the state of PA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0000027186 . This is a "MEDICARE" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 376852 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 001746361 0003 . This is a "PA DEPT OF HUMAN SERVICES" identifier , issued by the state of ( PA ) . This identifiers is of the category "OTHER".
  • Identifier: 0017463610003 . This is a "PROMISE WELFARE" identifier . This identifiers is of the category "OTHER".
  • Identifier: 52269 . This is a "DAVIS" identifier . This identifiers is of the category "OTHER".




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