Provider Demographics
NPI:1003950684
Name:LISAC, GERALD T (MD)
Entity Type:Individual
Prefix:DR
First Name:GERALD
Middle Name:T
Last Name:LISAC
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 646
Mailing Address - Street 2:
Mailing Address - City:WEST LINN
Mailing Address - State:OR
Mailing Address - Zip Code:97068-0646
Mailing Address - Country:US
Mailing Address - Phone:503-557-3679
Mailing Address - Fax:503-557-3680
Practice Address - Street 1:276 SW FOREST COVE RD
Practice Address - Street 2:
Practice Address - City:WEST LINN
Practice Address - State:OR
Practice Address - Zip Code:97068-9401
Practice Address - Country:US
Practice Address - Phone:503-557-3679
Practice Address - Fax:503-557-3680
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD06539174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORD72976OtherPROV. HEALTH PLAN
OR107722Medicaid
ORD72976OtherPROV. HEALTH PLAN