Provider Demographics
NPI:1518056951
Name:POCIUS, LISA C
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:C
Last Name:POCIUS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:DENT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1800 N MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WHEATON
Mailing Address - State:IL
Mailing Address - Zip Code:60187-3112
Mailing Address - Country:US
Mailing Address - Phone:630-614-4960
Mailing Address - Fax:630-682-3727
Practice Address - Street 1:1800 N MAIN ST
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-3112
Practice Address - Country:US
Practice Address - Phone:630-614-4960
Practice Address - Fax:630-682-3727
Is Sole Proprietor?:No
Enumeration Date:2006-10-12
Last Update Date:2013-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036109833207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036109833Medicaid
ILP01144139OtherRAILROAD MEDICARE INDIVIDUAL PTAN
IL920540OtherMEDICARE PTAN (GROUP)
IL920540031OtherMEDICARE PTAN (INDIVIDUAL)
ILP01144139OtherRAILROAD MEDICARE INDIVIDUAL PTAN
IL920540OtherMEDICARE PTAN (GROUP)