Provider Demographics
NPI:1235104498
Name:LIS, KIMBERLY JEAN (MD)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:JEAN
Last Name:LIS
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 751803
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28275-1803
Mailing Address - Country:US
Mailing Address - Phone:336-712-0700
Mailing Address - Fax:336-712-0876
Practice Address - Street 1:1225 LEWISVILLE CLEMMONS RD
Practice Address - Street 2:
Practice Address - City:LEWISVILLE
Practice Address - State:NC
Practice Address - Zip Code:27023-8251
Practice Address - Country:US
Practice Address - Phone:336-712-0700
Practice Address - Fax:336-712-0876
Is Sole Proprietor?:No
Enumeration Date:2006-02-21
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2005-00855207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC896579AMedicaid
NC5901233Medicaid
NC896579AMedicaid
NC2042884AMedicare PIN
NC5901233Medicaid