Provider Demographics
NPI:1386671147
Name:LIS, STEVEN T (MD)
Entity Type:Individual
Prefix:
First Name:STEVEN
Middle Name:T
Last Name:LIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30000 SANTIAGO RD
Mailing Address - Street 2:
Mailing Address - City:TEMECULA
Mailing Address - State:CA
Mailing Address - Zip Code:92592-5115
Mailing Address - Country:US
Mailing Address - Phone:951-695-0700
Mailing Address - Fax:
Practice Address - Street 1:1770 IOWA AVE
Practice Address - Street 2:SUITE 280
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2430
Practice Address - Country:US
Practice Address - Phone:951-786-0801
Practice Address - Fax:951-786-0460
Is Sole Proprietor?:No
Enumeration Date:2006-06-27
Last Update Date:2009-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG879092085R0202X
OH350869482085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHP00357635OtherRAILROAD MEDICARE
OH000000500789OtherANTHEM
OH2695454Medicaid
OHP00357635OtherRAILROAD MEDICARE
OH2695454Medicaid
CA00G679091Medicare PIN
CA00G679090Medicare ID - Type Unspecified
OHLI4194201Medicare PIN