Provider Demographics
NPI:1689636904
Name:OLDHAM, LISA MARIE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE
Last Name:OLDHAM
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 1:7447 W TALCOTT AVE STE 454
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60631-3715
Mailing Address - Country:US
Mailing Address - Phone:773-631-5767
Mailing Address - Fax:
Practice Address - Street 1:7447 W TALCOTT AVE STE 454
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60631-3715
Practice Address - Country:US
Practice Address - Phone:773-631-5767
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2021-10-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-105494207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-105494Medicaid
IL02-0677500OtherFEDERAL TAX ID
ILH71298Medicare UPIN