MEDICARE: DR. LISA DURHAM O.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	152W00000X	Optometrist	2004017331	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1629074620
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA DURHAM O.D.

Provider Business Mailing Address
First Line	:	40 E NORTH ST
Second Line	:
City	:	EUREKA
State	:	MO
Zip	:	63025-1205
Country	:	US
Telephone Number	:	636-200-4393
Fax Number	:	636-938-2650

Provider Business Practice Location Address
First Line	:	54 THE LEGENDS PKWY STE 151
Second Line	:
City	:	EUREKA
State	:	MO
Zip	:	63025-3803
Country	:	US
Telephone Number	:	636-938-7010
Fax Number	:	636-938-7141

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/23/2005
Last Update Date	:	11/18/2014

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