Provider Demographics
NPI:1639161458
Name:ODABASI, LISA (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:ODABASI
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 1:11803 JEFFERSON AVE
Mailing Address - Street 2:SUITE 230
Mailing Address - City:NEWPORT NEWS
Mailing Address - State:VA
Mailing Address - Zip Code:23606-2565
Mailing Address - Country:US
Mailing Address - Phone:757-534-7701
Mailing Address - Fax:757-534-7708
Practice Address - Street 1:11803 JEFFERSON AVE
Practice Address - Street 2:SUITE 230
Practice Address - City:NEWPORT NEWS
Practice Address - State:VA
Practice Address - Zip Code:23606-2565
Practice Address - Country:US
Practice Address - Phone:757-534-7701
Practice Address - Fax:757-534-7708
Is Sole Proprietor?:No
Enumeration Date:2005-08-18
Last Update Date:2011-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101044841207RG0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0100XAllopathic & Osteopathic PhysiciansInternal MedicineGastroenterology
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA6002676Medicaid
VA6002676Medicaid
VA110004951Medicare ID - Type Unspecified
VA100005333Medicare ID - Type UnspecifiedRAILROAD
VA110004882Medicare ID - Type Unspecified
VAE17654Medicare UPIN