Provider Demographics
NPI:1457309973
Name:EGBERT, LISA BOHMAN (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:BOHMAN
Last Name:EGBERT
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 1:7095 CLYO RD
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45459-4816
Mailing Address - Country:US
Mailing Address - Phone:937-433-8212
Mailing Address - Fax:877-590-2252
Practice Address - Street 1:7095 CLYO RD
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45459-4816
Practice Address - Country:US
Practice Address - Phone:937-433-8212
Practice Address - Fax:877-590-2252
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-05
Last Update Date:2024-02-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067040207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH311493673OtherCARESOURCE
OH74047OtherBC/BS
OH311493673OtherAULTCARE
OH2066179Medicaid
OHD6704004OtherCHOICECARE
OH2195193OtherAETNA
OHEG4010751Medicare ID - Type Unspecified
OH2066179Medicaid