Provider Demographics
NPI:1124228010
Name:CLAY, LISA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:CLAY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:RENEE
Other - Last Name:WARD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:210 N CELIA AVE
Mailing Address - Street 2:
Mailing Address - City:MUNCIE
Mailing Address - State:IN
Mailing Address - Zip Code:47303
Mailing Address - Country:US
Mailing Address - Phone:765-702-4633
Mailing Address - Fax:
Practice Address - Street 1:210 N CELIA AVE
Practice Address - Street 2:
Practice Address - City:MUNCIE
Practice Address - State:IN
Practice Address - Zip Code:47303
Practice Address - Country:US
Practice Address - Phone:765-702-4633
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-07-19
Last Update Date:2022-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01065883A207Q00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200931520AMedicaid
IN203170WWWWMedicare PIN