Provider Demographics
NPI:1396170015
Name:WAHL, LISA M (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:M
Last Name:WAHL
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 1:2330 W LIVE OAK DR
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90068-2530
Mailing Address - Country:US
Mailing Address - Phone:213-447-6495
Mailing Address - Fax:
Practice Address - Street 1:2330 W LIVE OAK DR
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90068-2530
Practice Address - Country:US
Practice Address - Phone:213-447-6495
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-12
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14724152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist