Provider Demographics
NPI:1215962915
Name:PORTER, LISA L (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:PORTER
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:852 E PARRI DR
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83401-5626
Mailing Address - Country:US
Mailing Address - Phone:208-757-0441
Mailing Address - Fax:208-656-7713
Practice Address - Street 1:1480 E LINCOLN RD STE B
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83401-2128
Practice Address - Country:US
Practice Address - Phone:208-525-8686
Practice Address - Fax:208-525-8684
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-11
Last Update Date:2011-11-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDODP-10013152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID000807525000Medicaid
ID27-1981532OtherIRS ITIN
ID15945511Medicare PIN
ID27-1981532OtherIRS ITIN