Provider Demographics
NPI:1548303928
Name:CARROLL, LISA ANN (OD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:ANN
Last Name:CARROLL
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 1:1040 BARNUM AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-4968
Mailing Address - Country:US
Mailing Address - Phone:203-378-2269
Mailing Address - Fax:203-377-7207
Practice Address - Street 1:1040 BARNUM AVE
Practice Address - Street 2:
Practice Address - City:STRATFORD
Practice Address - State:CT
Practice Address - Zip Code:06614-4968
Practice Address - Country:US
Practice Address - Phone:203-378-2269
Practice Address - Fax:203-377-7207
Is Sole Proprietor?:No
Enumeration Date:2007-02-15
Last Update Date:2010-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT999152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004161717Medicaid
CTT22300Medicare UPIN
CT004161717Medicaid