Provider Demographics
NPI:1467455808
Name:WATERMAN, LISA RENEE (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:WATERMAN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 E ROBINSON ST
Mailing Address - Street 2:STE 2400
Mailing Address - City:NORMAN
Mailing Address - State:OK
Mailing Address - Zip Code:73071-6671
Mailing Address - Country:US
Mailing Address - Phone:405-360-1264
Mailing Address - Fax:405-321-8683
Practice Address - Street 1:500 E ROBINSON ST
Practice Address - Street 2:STE 2400
Practice Address - City:NORMAN
Practice Address - State:OK
Practice Address - Zip Code:73071-6671
Practice Address - Country:US
Practice Address - Phone:405-360-1264
Practice Address - Fax:405-321-8683
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2008-08-28
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
OK3499207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100148640AMedicaid
OK$$$$$$$$$Medicare PIN
OKH45258Medicare UPIN