MEDICARE: LISA M WILSON O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	13706	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	11338TG	OTHER	TX	OPTOMETRIST

General Provider Information

NPI Number	:	1861487613
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M WILSON O.D.

Provider Business Mailing Address
First Line	:	2432 AVONDALE HASLET RD STE 200
Second Line	:
City	:	HASLET
State	:	TX
Zip	:	76052-3428
Country	:	US
Telephone Number	:	817-993-2020
Fax Number	:

Provider Business Practice Location Address
First Line	:	2432 AVONDALE HASLET RD STE 200
Second Line	:
City	:	HASLET
State	:	TX
Zip	:	76052-3428
Country	:	US
Telephone Number	:	817-993-2020
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/19/2005
Last Update Date	:	10/14/2025

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