Provider Demographics
NPI:1235267915
Name:LISA CORSTVET MD PC
Entity Type:Organization
Organization Name:LISA CORSTVET MD PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CATHY
Authorized Official - Middle Name:
Authorized Official - Last Name:PRICE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-775-9350
Mailing Address - Street 1:3705 W MEMORIAL RD
Mailing Address - Street 2:302
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73134-1512
Mailing Address - Country:US
Mailing Address - Phone:405-775-9350
Mailing Address - Fax:405-775-9360
Practice Address - Street 1:3705 W MEMORIAL RD
Practice Address - Street 2:302
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1512
Practice Address - Country:US
Practice Address - Phone:405-775-9350
Practice Address - Fax:405-775-9360
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-02
Last Update Date:2008-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16541174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200110200AMedicaid
OK612216600OtherDOL
OKDF8730OtherMEDICARE RR
OKDF8730OtherMEDICARE RR
OKE85767Medicare UPIN
OK=========001OtherBC/BS