Healthcare Provider Details

I. General information

NPI: 1235563040
Provider Name (Legal Business Name): LISBET VIDAL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/28/2013
Last Update Date: 03/19/2025
Certification Date: 03/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4330 SHERIDAN ST STE 102
HOLLYWOOD FL
33021-1406
US

IV. Provider business mailing address

4330 SHERIDAN ST STE 102
HOLLYWOOD FL
33021-1406
US

V. Phone/Fax

Practice location:
  • Phone: 954-287-2010
  • Fax:
Mailing address:
  • Phone: 954-287-2010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberOPC4792
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: