Provider Demographics
NPI:1629197041
Name:MIMS, LISA ANNETTE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ANNETTE
Last Name:MIMS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:550 N. UNIVERSITY BLVD,
Practice Address - Street 2:UH2440
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46202-5274
Practice Address - Country:US
Practice Address - Phone:317-217-2400
Practice Address - Fax:317-278-9918
Is Sole Proprietor?:No
Enumeration Date:2007-03-28
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036096055207V00000X
IL036.096055207V00000X
IN01058650A207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200924630Medicaid
IN200924630Medicaid