Provider Demographics
NPI:1083628044
Name:CORSTVET, LISA MARGARET (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARGARET
Last Name:CORSTVET
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 975008
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75397-5008
Mailing Address - Country:US
Mailing Address - Phone:405-418-4800
Mailing Address - Fax:405-418-4820
Practice Address - Street 1:4317 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1720
Practice Address - Country:US
Practice Address - Phone:405-418-4800
Practice Address - Fax:405-418-4820
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-27
Last Update Date:2020-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK16541207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK612216600OtherDOL
OK100107550AMedicaid
OKP00398663OtherMEDICARE RR
OKP00398663OtherMEDICARE RR
OK612216600OtherDOL