Provider Demographics
NPI:1679527253
Name:DIBLER, LISA B (OD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:B
Last Name:DIBLER
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 1:266 LAMP AND LANTERN VLG
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63017-8209
Mailing Address - Country:US
Mailing Address - Phone:636-527-8877
Mailing Address - Fax:636-527-8897
Practice Address - Street 1:266 LAMP AND LANTERN VLG
Practice Address - Street 2:
Practice Address - City:CHESTERFIELD
Practice Address - State:MO
Practice Address - Zip Code:63017-8209
Practice Address - Country:US
Practice Address - Phone:636-527-8877
Practice Address - Fax:636-527-8897
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-19
Last Update Date:2013-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MOT03159152WV0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WV0400XEye and Vision Services ProvidersOptometristVision Therapy
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOU44100Medicare UPIN
MO000014295Medicare ID - Type Unspecified