Provider Demographics
NPI:1508892449
Name:THOMAS, LISA R (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:THOMAS
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 1:301C US ROUTE ONE
Mailing Address - Street 2:
Mailing Address - City:SCARBOROUGH
Mailing Address - State:ME
Mailing Address - Zip Code:04074-9701
Mailing Address - Country:US
Mailing Address - Phone:207-396-8600
Mailing Address - Fax:207-396-8632
Practice Address - Street 1:119 GANNETT DR
Practice Address - Street 2:
Practice Address - City:SOUTH PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04106-6942
Practice Address - Country:US
Practice Address - Phone:207-774-2642
Practice Address - Fax:207-774-4293
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MEMD15368207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
ME269070099Medicaid
NH30201604Medicaid
038667OtherANTHEM
038667OtherANTHEM
MEMM826103Medicare PIN
MEMM8261Medicare PIN
MEMM826102Medicare PIN
G60657Medicare UPIN