Individual
DR. LISA G. WALLACE-DAVIS
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
OD
Contact information
Practice address
1134 BIG BETHEL RD, HAMPTON, VA 23666-1906
(757) 827-6612
(757) 827-6296
Mailing address
1134 BIG BETHEL RD, HAMPTON, VA 23666-1906
(757) 827-6612
(757) 827-6296
Taxonomy
Speciality
Code
Description
License number
State
152W00000X
Optometrist
Primary
0618000303
VA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
009232583
—
VA
01
—
0618000303
STATE LICENSE
VA
01
—
541786245
TAX ID
—
Enumeration date
07/06/2006
Last updated
12/15/2011
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