Provider Demographics
NPI:1174506315
Name:MURPHY, LISA WYNETTE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:WYNETTE
Last Name:MURPHY
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 1:830 SCENIC DR
Mailing Address - Street 2:
Mailing Address - City:MODESTO
Mailing Address - State:CA
Mailing Address - Zip Code:95350-6131
Mailing Address - Country:US
Mailing Address - Phone:209-558-7248
Mailing Address - Fax:209-558-8723
Practice Address - Street 1:200 W COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95350-4447
Practice Address - Country:US
Practice Address - Phone:209-577-5005
Practice Address - Fax:209-521-1533
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-22
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ50015207V00000X
MI4301056342207VG0400X
CAC148024207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGroup - Single Specialty
No207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI160D410050OtherBLUE CROSS BLUE SHIELD
MI160D410050OtherCOMMUNITY BLUE
MI4380839Medicaid
MIG93281OtherHEALTH NET FEDERAL SERVIC
MI0982797OtherHEALTHPLUS
MI203333OtherHEALTH ADVANTAGE
MI34649164Medicaid
MIC5869OtherMCARE
MI01338OtherAETNA
MI160D410050OtherBLUE CARE NETWORK
MI203333OtherMCLAREN HEALTH PLAN
MI1602503852OtherBLUE CROSS BLUE SHIELD
MI160D410050OtherBLUE CHOICE
MIG93281OtherHAP
MI203333OtherHEALTH ADVANTAGE
MI0982797OtherHEALTHPLUS