Healthcare Provider Details

I. General information

NPI: 1619956794
Provider Name (Legal Business Name): LISA ANN TRAVEIS O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2006
Last Update Date: 06/20/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

21 MARKET STREET STE. 100
IPSWICH MA
01938
US

IV. Provider business mailing address

21 MARKET STREET STE. 100
IPSWICH MA
01938
US

V. Phone/Fax

Practice location:
  • Phone: 978-356-3015
  • Fax: 978-356-7525
Mailing address:
  • Phone: 978-356-3015
  • Fax: 978-356-7525

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3308
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberMA3308
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: