Provider Demographics
NPI:1619957164
Name:HOLTSCLAW, LISA MICHELLE (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MICHELLE
Last Name:HOLTSCLAW
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 W MONROE ST STE 1200
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60603-2420
Mailing Address - Country:US
Mailing Address - Phone:312-733-9730
Mailing Address - Fax:773-866-8014
Practice Address - Street 1:436 E WASHINGTON BLVD
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46802-3210
Practice Address - Country:US
Practice Address - Phone:260-209-7111
Practice Address - Fax:260-222-2835
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN02001568A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN100373060Medicaid
IN069860EMedicare ID - Type Unspecified
IN100373060Medicaid