Provider Demographics
NPI:1992761092
Name:KANFOUSH, LISA RAE (OD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:RAE
Last Name:KANFOUSH
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:131 PLEASANT DR
Mailing Address - Street 2:SUITE #3
Mailing Address - City:ALIQUIPPA
Mailing Address - State:PA
Mailing Address - Zip Code:15001-1300
Mailing Address - Country:US
Mailing Address - Phone:724-378-4457
Mailing Address - Fax:724-378-4541
Practice Address - Street 1:131 PLEASANT DR
Practice Address - Street 2:SUITE #3
Practice Address - City:ALIQUIPPA
Practice Address - State:PA
Practice Address - Zip Code:15001-1300
Practice Address - Country:US
Practice Address - Phone:724-378-4457
Practice Address - Fax:724-378-4541
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-26
Last Update Date:2007-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAOEG001382152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PAU45727Medicare UPIN
PA456692Medicare ID - Type Unspecified
PA01738243Medicare ID - Type Unspecified