Provider Demographics
NPI:1427059146
Name:MITCHELL, LISA L (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:MITCHELL
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 1:425 SAINT MARY ST
Mailing Address - Street 2:
Mailing Address - City:THIBODAUX
Mailing Address - State:LA
Mailing Address - Zip Code:70301-2641
Mailing Address - Country:US
Mailing Address - Phone:985-447-2393
Mailing Address - Fax:
Practice Address - Street 1:425 SAINT MARY ST
Practice Address - Street 2:
Practice Address - City:THIBODAUX
Practice Address - State:LA
Practice Address - Zip Code:70301-2641
Practice Address - Country:US
Practice Address - Phone:985-447-2393
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-03
Last Update Date:2016-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0618001392152W00000X
NC1960152W00000X
LA1412-554T152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
4K179C398OtherMEDICARE-UNSPECIFIED
LA1010421Medicaid
LA1010421Medicaid
VAV00487Medicare UPIN