Provider Demographics
NPI:1528012960
Name:HUTTO, LISA S (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:S
Last Name:HUTTO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:STE 430
Mailing Address - Street 2:9 RICHLAND MEDICAL PK
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29203-6870
Mailing Address - Country:US
Mailing Address - Phone:803-765-9435
Mailing Address - Fax:803-765-2446
Practice Address - Street 1:STE 430
Practice Address - Street 2:9 RICHLAND MEDICAL PK
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29203-6870
Practice Address - Country:US
Practice Address - Phone:803-765-9435
Practice Address - Fax:803-765-2446
Is Sole Proprietor?:No
Enumeration Date:2006-05-20
Last Update Date:2007-10-29
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
SC12987207K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207K00000XAllopathic & Osteopathic PhysiciansAllergy & Immunology
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC12987OtherLICENSE #
SCGP1022Medicaid
SC6775Medicare PIN
SC12987OtherLICENSE #