Provider Demographics
NPI:1306843677
Name:SOVORY, LISA HERRING (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:HERRING
Last Name:SOVORY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:MONIQUE
Other - Last Name:HERRING
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:6185 MAGNOLIA AVE
Mailing Address - Street 2:SUITE 354
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-2524
Mailing Address - Country:US
Mailing Address - Phone:951-335-0193
Mailing Address - Fax:951-335-0194
Practice Address - Street 1:6086 BROCKTON AVE
Practice Address - Street 2:SUITE 1
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-2227
Practice Address - Country:US
Practice Address - Phone:951-335-0193
Practice Address - Fax:951-335-0194
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2015-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA800372084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4684306Medicaid
0M94160004Medicare PIN
MI4684306Medicaid