Provider Demographics
NPI:1164470647
Name:KAO, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KAO
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:PO BOX 9602
Mailing Address - Street 2:
Mailing Address - City:MISSION HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91346-9602
Mailing Address - Country:US
Mailing Address - Phone:818-837-5691
Mailing Address - Fax:818-792-4793
Practice Address - Street 1:191 S BUENA VISTA ST
Practice Address - Street 2:SUITE 100
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505-4554
Practice Address - Country:US
Practice Address - Phone:855-723-3005
Practice Address - Fax:855-817-9681
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ25MA06938700208000000X
CAC53552208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00C535520Medicaid
CAEK374YMedicare PIN
CAEK374ZMedicare PIN
077356 SK3Medicare PIN