Provider Demographics
NPI:1184840043
Name:KLANKE, LISA WEIDER (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:WEIDER
Last Name:KLANKE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:KAYE
Other - Last Name:WEIDER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:25 MERCHANT STREET
Mailing Address - Street 2:SUITE 220
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45246-3740
Mailing Address - Country:US
Mailing Address - Phone:513-533-6507
Mailing Address - Fax:513-645-9767
Practice Address - Street 1:6551 CENTERVILLE BUSINESS PKWY STE 110
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-2696
Practice Address - Country:US
Practice Address - Phone:937-291-6850
Practice Address - Fax:937-291-6896
Is Sole Proprietor?:No
Enumeration Date:2007-04-18
Last Update Date:2020-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH57-010522208000000X
OH35.091257208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2896086Medicaid