Provider Demographics
NPI:1417966235
Name:OLTMANNS, LISA MOODY (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MOODY
Last Name:OLTMANNS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:M
Other - Last Name:MOODY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3621 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48108-1633
Mailing Address - Country:US
Mailing Address - Phone:734-647-5299
Mailing Address - Fax:
Practice Address - Street 1:8001 CHALLIS RD
Practice Address - Street 2:
Practice Address - City:BRIGHTON
Practice Address - State:MI
Practice Address - Zip Code:48116-7446
Practice Address - Country:US
Practice Address - Phone:734-998-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-08-08
Last Update Date:2023-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301072992207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0994924OtherHEALTH PLUS
MICD3610 POO363004OtherMETRAHEALTH
MI11OB510530OtherBCN
MI4919805Medicaid
MI1021425OtherMCLAREN HEALTH PLAN
MI0994924OtherGENESEE HEALTH PLAN
MI110B510530OtherBCBS
MI1021425OtherMCLAREN HEALTH ADVANTAGE
MI12371OtherMCARE
MI2059767OtherFIRST HEALTH
MI1021425OtherMCLAREN HEALTH PLAN
MIG72380Medicare UPIN