Basic Information
| Provider Information | |||||||||
| NPI: | 1619354743 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | BENNETT | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | |||||||||
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| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | WASIELEWSKI | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | W. | ||||||||
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| OtherCredential: | MD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 788 N JEFFERSON ST STE 300 | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532023710 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142728950 | ||||||||
| FaxNumber: | 4142746250 | ||||||||
| Practice Location | |||||||||
| Address1: | 10320 N PORT WASHINGTON RD | ||||||||
| Address2: | |||||||||
| City: | MEQUON | ||||||||
| State: | WI | ||||||||
| PostalCode: | 530925767 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2622411919 | ||||||||
| FaxNumber: | 2622419046 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/27/2015 | ||||||||
| LastUpdateDate: | 06/25/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207W00000X | 2016014173 | MO | N | Allopathic & Osteopathic Physicians | Ophthalmology | 207W00000X | 70489 | WI | Y | Allopathic & Osteopathic Physicians | Ophthalmology |
No ID Information.