Provider Demographics
NPI:1437198066
Name:VANTREASE, LISA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:VANTREASE
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 1:2145 N FAIRFIELD RD STE 100
Mailing Address - Street 2:
Mailing Address - City:BEAVERCREEK
Mailing Address - State:OH
Mailing Address - Zip Code:45431-2783
Mailing Address - Country:US
Mailing Address - Phone:937-558-3900
Mailing Address - Fax:937-558-3999
Practice Address - Street 1:2145 N FAIRFIELD RD STE 100
Practice Address - Street 2:
Practice Address - City:BEAVERCREEK
Practice Address - State:OH
Practice Address - Zip Code:45431
Practice Address - Country:US
Practice Address - Phone:937-558-3900
Practice Address - Fax:937-558-3999
Is Sole Proprietor?:No
Enumeration Date:2006-06-06
Last Update Date:2020-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35-075877207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2159373Medicaid
OH2159373Medicaid
OH0887776Medicare PIN
H02248Medicare UPIN
OH0887777Medicare PIN
OH0887775Medicare PIN