Provider Demographics
NPI:1619354743
Name:BENNETT, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:BENNETT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:W
Other - Last Name:WASIELEWSKI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:788 N JEFFERSON ST STE 300
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53202-3710
Mailing Address - Country:US
Mailing Address - Phone:414-272-8950
Mailing Address - Fax:414-274-6250
Practice Address - Street 1:10320 N PORT WASHINGTON RD
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-5767
Practice Address - Country:US
Practice Address - Phone:262-241-1919
Practice Address - Fax:262-241-9046
Is Sole Proprietor?:No
Enumeration Date:2015-04-27
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2016014173207W00000X
WI70489207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1619354743Medicaid