Provider Demographics
NPI:1104827799
Name:MEDWEDEFF, LISA ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELAINE
Last Name:MEDWEDEFF
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 1:5425 W SPRING CREEK PARKWAY SUITE 210
Mailing Address - Street 2:
Mailing Address - City:PLANO
Mailing Address - State:TX
Mailing Address - Zip Code:75024
Mailing Address - Country:US
Mailing Address - Phone:972-608-3333
Mailing Address - Fax:972-473-7333
Practice Address - Street 1:5425 W SPRING CREEK PARKWAY SUITE 210
Practice Address - Street 2:
Practice Address - City:PLANO
Practice Address - State:TX
Practice Address - Zip Code:75024
Practice Address - Country:US
Practice Address - Phone:972-608-3333
Practice Address - Fax:972-473-7333
Is Sole Proprietor?:Yes
Enumeration Date:2005-08-03
Last Update Date:2020-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXK1257173000000X, 207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No173000000XOther Service ProvidersLegal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX0299083-01Medicaid
0025BQMedicare PIN
TX0299083-01Medicaid