Provider Demographics
NPI:1407803117
Name:DEWINTER, LISA L (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:DEWINTER
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 1:5750 E OLD PAINT TRAIL
Mailing Address - Street 2:
Mailing Address - City:CAREFREE
Mailing Address - State:AZ
Mailing Address - Zip Code:85377
Mailing Address - Country:US
Mailing Address - Phone:517-304-0652
Mailing Address - Fax:
Practice Address - Street 1:1500 S MILL AVE
Practice Address - Street 2:
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85281
Practice Address - Country:US
Practice Address - Phone:517-304-0652
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-05-28
Last Update Date:2017-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI060204207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3433240Medicaid
MILW060204OtherBC/BS
MILW060204OtherBC/BS
MIG16481Medicare UPIN