Healthcare Provider Details

I. General information

NPI: 1144215864
Provider Name (Legal Business Name): LISA M TESTA O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 01/15/2021
Certification Date: 01/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2694 S MAIN ST
COVENTRY TOWNSHIP OH
44319-1861
US

IV. Provider business mailing address

2694 S MAIN ST
COVENTRY TOWNSHIP OH
44319-1861
US

V. Phone/Fax

Practice location:
  • Phone: 330-785-5111
  • Fax: 330-785-5114
Mailing address:
  • Phone: 330-785-5111
  • Fax: 330-785-5114

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number4179-T681
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: