Provider Demographics
NPI:1518903426
Name:DRAKE, LISA DANIELLE (OD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DANIELLE
Last Name:DRAKE
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 1:1075 OLD GOLF COURSE RD
Mailing Address - Street 2:
Mailing Address - City:BATESBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29006-9857
Mailing Address - Country:US
Mailing Address - Phone:803-960-2807
Mailing Address - Fax:
Practice Address - Street 1:1000 CLYBURN PL
Practice Address - Street 2:
Practice Address - City:AIKEN
Practice Address - State:SC
Practice Address - Zip Code:29801-4193
Practice Address - Country:US
Practice Address - Phone:803-380-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2025-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC1018152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC20047639OtherSELECT HEALTH OF SC
SCD10183Medicaid
SCD10183Medicaid