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General NPI Number Information
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NPI Number | 1124283767
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Entity Type | Individual
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Provider Name | LISA G DOMINO O.D.
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Gender | Female
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Dates
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Enumeration Date | 07/23/2008
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Last Update Date | 07/21/2022
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Provider Practice Location Address
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Address Line | 2510 SW WHITE BIRCH DR STE 5
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City | ANKENY
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State | IA
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Zip | 50023-7171
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Country | US
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Telephone | 515-450-1339
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Fax | 515-964-3277
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Provider Business Mailing Address
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Address Line | 2510 SW WHITE BIRCH DR STE 5
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City | ANKENY
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State | IA
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Zip | 50023-7171
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Country | US
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Telephone | 515-450-1339
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 152W00000X
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Taxonomy Name | Optometrist
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License Number | 002438
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License Number State | IA
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