Provider Demographics
NPI:1275743684
Name:ORTIZ, LISA D (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:D
Last Name:ORTIZ
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 1:1483 DEER RUN DR
Mailing Address - Street 2:
Mailing Address - City:FORT GIBSON
Mailing Address - State:OK
Mailing Address - Zip Code:74434-9351
Mailing Address - Country:US
Mailing Address - Phone:918-478-2267
Mailing Address - Fax:
Practice Address - Street 1:301 J T STITES BLVD
Practice Address - Street 2:REDBIRD SMITH HEALTH CENTER
Practice Address - City:SALLISAW
Practice Address - State:OK
Practice Address - Zip Code:74955-9302
Practice Address - Country:US
Practice Address - Phone:918-775-9159
Practice Address - Fax:918-775-6469
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2008-04-23
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OK25970207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine