Provider Demographics
NPI:1366440273
Name:MCKENNA, LISA FOGEL (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:FOGEL
Last Name:MCKENNA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:E
Other - Last Name:FOGEL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MD
Mailing Address - Street 1:2605 BLUE RIDGE RD STE 320
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27607-6475
Mailing Address - Country:US
Mailing Address - Phone:919-787-8555
Mailing Address - Fax:919-787-8112
Practice Address - Street 1:2605 BLUE RIDGE RD STE 320
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-6475
Practice Address - Country:US
Practice Address - Phone:919-787-8555
Practice Address - Fax:919-787-8112
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-13
Last Update Date:2023-11-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2006-00726207WX0107X, 207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207WX0107XAllopathic & Osteopathic PhysiciansOphthalmologyRetina Specialist
No207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5903995Medicaid
NC5903995Medicaid