Provider Demographics
NPI:1861420283
Name:CAMMETT, LISA (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:CAMMETT
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 1:4123 S MICHIGAN ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46614-2545
Mailing Address - Country:US
Mailing Address - Phone:574-291-8900
Mailing Address - Fax:574-299-8503
Practice Address - Street 1:4123 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-2545
Practice Address - Country:US
Practice Address - Phone:574-291-8900
Practice Address - Fax:574-299-8503
Is Sole Proprietor?:No
Enumeration Date:2006-06-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN18002914152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN164240WMedicare ID - Type Unspecified
INU70088Medicare UPIN