Provider Demographics
NPI:1659357143
Name:DAVID, LISA RENEE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RENEE
Last Name:DAVID
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 1:100 KIMEL FOREST DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6074
Mailing Address - Country:US
Mailing Address - Phone:336-716-0238
Mailing Address - Fax:
Practice Address - Street 1:MEDICAL CENTER BLVD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27157-0001
Practice Address - Country:US
Practice Address - Phone:336-716-4171
Practice Address - Fax:336-716-8759
Is Sole Proprietor?:No
Enumeration Date:2005-12-16
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9400459208200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208200000XAllopathic & Osteopathic PhysiciansPlastic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8927161Medicaid
WV2005471000Medicaid
NC4575678OtherAETNA
NC97072OtherMEDCOST
SCQ0045AMedicaid
NC8440OtherPARTNERS
NC27161OtherBCBS
VA6900615Medicaid
NC4575678OtherAETNA
SCQ0045AMedicaid