Provider Demographics
NPI:1235545278
Name:DEMIDOWICH, LISA (DPM)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:DEMIDOWICH
Suffix:
Gender:F
Credentials:DPM
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 27077
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86312-7077
Mailing Address - Country:US
Mailing Address - Phone:928-225-2540
Mailing Address - Fax:
Practice Address - Street 1:2286 CROSSWIND DR STE C
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-6100
Practice Address - Country:US
Practice Address - Phone:928-225-2540
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-07-10
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
AZ0844213ES0103X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213ES0103XPodiatric Medicine & Surgery Service ProvidersPodiatristFoot & Ankle Surgery
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program