Provider Demographics
NPI:1376578187
Name:HALL, LISABETH C (MD)
Entity Type:Individual
Prefix:
First Name:LISABETH
Middle Name:C
Last Name:HALL
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 1:5450 WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:BOULDER
Mailing Address - State:CO
Mailing Address - Zip Code:80301-2709
Mailing Address - Country:US
Mailing Address - Phone:303-415-4325
Mailing Address - Fax:303-661-9496
Practice Address - Street 1:1000 W SOUTH BOULDER RD
Practice Address - Street 2:SUITE 214
Practice Address - City:LAFAYETTE
Practice Address - State:CO
Practice Address - Zip Code:80026-2752
Practice Address - Country:US
Practice Address - Phone:303-604-6669
Practice Address - Fax:303-604-5095
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2017-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CODR.0051961207R00000X
CA54785207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO49452258Medicaid
CA155349Medicare UPIN
CO49452258Medicaid
CA34362201Medicare PIN