Provider Demographics
NPI:1144337650
Name:TEEL, LISA (OD)
Entity type:Individual
Prefix:MR
First Name:LISA
Middle Name:
Last Name:TEEL
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 1:50 PROFESSIONAL CENTER DR
Mailing Address - Street 2:SUITE 210
Mailing Address - City:ROHNERT PARK
Mailing Address - State:CA
Mailing Address - Zip Code:94928-2164
Mailing Address - Country:US
Mailing Address - Phone:707-996-1052
Mailing Address - Fax:707-996-6787
Practice Address - Street 1:545 3RD ST W
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-6501
Practice Address - Country:US
Practice Address - Phone:707-996-1052
Practice Address - Fax:707-996-6787
Is Sole Proprietor?:No
Enumeration Date:2006-08-23
Last Update Date:2011-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT9704152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAOPT9704OtherLICENSE