Provider Demographics
NPI:1588624571
Name:DAVIS, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DAVIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANN
Other - Last Name:MUMMAW
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:3 WALNUT ST
Mailing Address - Street 2:SUITE 206
Mailing Address - City:LEMOYNE
Mailing Address - State:PA
Mailing Address - Zip Code:17043-1168
Mailing Address - Country:US
Mailing Address - Phone:717-761-0208
Mailing Address - Fax:717-761-2023
Practice Address - Street 1:4470 VALLEY ST
Practice Address - Street 2:
Practice Address - City:ENOLA
Practice Address - State:PA
Practice Address - Zip Code:17025-1443
Practice Address - Country:US
Practice Address - Phone:717-732-8883
Practice Address - Fax:717-732-1640
Is Sole Proprietor?:No
Enumeration Date:2006-03-24
Last Update Date:2009-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD042461L207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
E80605Medicare UPIN
PA654925Medicare ID - Type Unspecified