Provider Demographics
NPI:1053328989
Name:DODSON, LISA GRILL (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:GRILL
Last Name:DODSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2720 PLAZA DR
Mailing Address - Street 2:SUITE 1100
Mailing Address - City:WAUSAU
Mailing Address - State:WI
Mailing Address - Zip Code:54401-4158
Mailing Address - Country:US
Mailing Address - Phone:715-847-2472
Mailing Address - Fax:
Practice Address - Street 1:2720 PLAZA DR
Practice Address - Street 2:SUITE 1100
Practice Address - City:WAUSAU
Practice Address - State:WI
Practice Address - Zip Code:54401-4158
Practice Address - Country:US
Practice Address - Phone:715-847-2472
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-02
Last Update Date:2021-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI63624207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR024096Medicaid
OR024096Medicaid