Healthcare Provider Details

I. General information

NPI: 1518349224
Provider Name (Legal Business Name): LISA STUART VANDERPOOL O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA CHERYL STUART O.D.

II. Dates (important events)

Enumeration Date: 06/18/2015
Last Update Date: 07/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9440 IRON BRIDGE RD
CHESTERFIELD VA
23832-6601
US

IV. Provider business mailing address

14212 PALLADIUM DR APT 203
MIDLOTHIAN VA
23114-6808
US

V. Phone/Fax

Practice location:
  • Phone: 804-748-4877
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number3239
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: