Healthcare Provider Details

I. General information

NPI: 1952303042
Provider Name (Legal Business Name): LISA ANDERSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2005
Last Update Date: 12/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9909 GEORGETOWN PIKE
GREAT FALLS VA
22066-2826
US

IV. Provider business mailing address

9909 GEORGETOWN PIKE
GREAT FALLS VA
22066-2826
US

V. Phone/Fax

Practice location:
  • Phone: 703-759-0061
  • Fax: 703-759-0063
Mailing address:
  • Phone: 703-759-0061
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0618000206
License Number StateVA
# 2
Primary TaxonomyN
Taxonomy Code152W00000X
TaxonomyOptometrist
License NumberDA1065
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: