Healthcare Provider Details

I. General information

NPI: 1861487613
Provider Name (Legal Business Name): LISA M WILSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/19/2005
Last Update Date: 10/14/2025
Certification Date: 10/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2432 AVONDALE HASLET RD STE 200
HASLET TX
76052-3428
US

IV. Provider business mailing address

2432 AVONDALE HASLET RD STE 200
HASLET TX
76052-3428
US

V. Phone/Fax

Practice location:
  • Phone: 817-993-2020
  • Fax:
Mailing address:
  • Phone: 817-993-2020
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number13706
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: