Provider Demographics
NPI:1528044484
Name:BURKE, LISA L (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:BURKE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
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Mailing Address - Street 1:5700 MONROE ST UNIT 203
Mailing Address - Street 2:
Mailing Address - City:SYLVANIA
Mailing Address - State:OH
Mailing Address - Zip Code:43560-2735
Mailing Address - Country:US
Mailing Address - Phone:419-843-8100
Mailing Address - Fax:419-841-4681
Practice Address - Street 1:5700 MONROE ST UNIT 203
Practice Address - Street 2:
Practice Address - City:SYLVANIA
Practice Address - State:OH
Practice Address - Zip Code:43560-2735
Practice Address - Country:US
Practice Address - Phone:419-843-8100
Practice Address - Fax:419-841-4681
Is Sole Proprietor?:No
Enumeration Date:2005-12-21
Last Update Date:2023-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH34.007455207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH080184742OtherRAILROAD MEDICARE
MILB016293OtherMI BC
OH725860OtherBUCKEYE
OH000000213037OtherANTHEM
OH04283OtherPARAMOUNT
OH2320652Medicaid
OH7837353OtherAETNA
MI114696998Medicaid
OHP00198234OtherRAILROAD MEDICARE
MIP04960002Medicare PIN
OH04283OtherPARAMOUNT
MILB016293OtherMI BC