Healthcare Provider Details

I. General information

NPI: 1649228933
Provider Name (Legal Business Name): LISA MARTIN ERIKSSON O.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/05/2006
Last Update Date: 06/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 HINESBURG RD SUITE 201
SOUTH BURLINGTON VT
05403-7613
US

IV. Provider business mailing address

1100 HINESBURG RD SUITE 201
SOUTH BURLINGTON VT
05403-7613
US

V. Phone/Fax

Practice location:
  • Phone: 802-862-1808
  • Fax:
Mailing address:
  • Phone: 802-862-1808
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number0300000262
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: