Provider Demographics
NPI:1235185406
Name:DAVIDSON, LISA DIANE (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:DIANE
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:DO
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Mailing Address - Street 1:2373 CENTRAL PARK BLVD UNIT 205
Mailing Address - Street 2:
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80238-2300
Mailing Address - Country:US
Mailing Address - Phone:303-377-2494
Mailing Address - Fax:303-377-2548
Practice Address - Street 1:2373 CENTRAL PARK BLVD UNIT 205
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80238-2300
Practice Address - Country:US
Practice Address - Phone:303-377-2494
Practice Address - Fax:303-377-2548
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2014-04-02
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
CO37134207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO141898808OtherTAX ID
COH13841Medicare UPIN