Provider Demographics
NPI:1659372050
Name:VICKERS, LISA L (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:L
Last Name:VICKERS
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 1:7575 5 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45230-4346
Mailing Address - Country:US
Mailing Address - Phone:513-981-6784
Mailing Address - Fax:513-232-2522
Practice Address - Street 1:7575 5 MILE RD
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45230-4346
Practice Address - Country:US
Practice Address - Phone:513-981-6784
Practice Address - Fax:513-232-2522
Is Sole Proprietor?:No
Enumeration Date:2005-08-09
Last Update Date:2020-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH64003207X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207X00000XAllopathic & Osteopathic PhysiciansOrthopaedic Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH382018Medicaid
OHG38536Medicare UPIN