Provider Demographics
NPI:1619923190
Name:OVERTON, LISA CAROL (DPM)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CAROL
Last Name:OVERTON
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1940 E WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1312
Mailing Address - Country:US
Mailing Address - Phone:215-548-2113
Mailing Address - Fax:215-548-3009
Practice Address - Street 1:1940 E WALNUT LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1312
Practice Address - Country:US
Practice Address - Phone:215-548-2113
Practice Address - Fax:215-548-3009
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-26
Last Update Date:2011-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004492L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA0018442730002Medicaid
PA2063808000OtherIBC 10 DIGIT HMO ID
PA10741OtherELDER HEALTH ID
PA5403600001OtherDMERC SUPPLIER ID
PA001372137OtherHIGHMARK BLUE SHIELD ID
PA5403600001OtherDMERC SUPPLIER ID
PA047229Medicare ID - Type Unspecified