Provider Demographics
NPI:1124283767
Name:DOMINO, LISA G (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:G
Last Name:DOMINO
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
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Mailing Address - Street 1:2510 SW WHITE BIRCH DR STE 5
Mailing Address - Street 2:
Mailing Address - City:ANKENY
Mailing Address - State:IA
Mailing Address - Zip Code:50023-7171
Mailing Address - Country:US
Mailing Address - Phone:515-450-1339
Mailing Address - Fax:
Practice Address - Street 1:2510 SW WHITE BIRCH DR STE 5
Practice Address - Street 2:
Practice Address - City:ANKENY
Practice Address - State:IA
Practice Address - Zip Code:50023-7171
Practice Address - Country:US
Practice Address - Phone:515-450-1339
Practice Address - Fax:515-964-3277
Is Sole Proprietor?:Yes
Enumeration Date:2008-07-23
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA002438152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist