Provider Demographics
NPI:1417954504
Name:WASEMILLER-SMITH, LISA J (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:WASEMILLER-SMITH
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 1:11200 N PORTLAND AVE
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73120-5045
Mailing Address - Country:US
Mailing Address - Phone:405-936-1100
Mailing Address - Fax:405-936-1122
Practice Address - Street 1:11200 N PORTLAND AVE
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73120-5045
Practice Address - Country:US
Practice Address - Phone:405-936-1100
Practice Address - Fax:405-936-1122
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-05
Last Update Date:2008-05-15
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-23
Provider Licenses
StateLicense IDTaxonomies
OKMD13137207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100824630AMedicaid
OK100824630CMedicaid
OK100824630CMedicaid