Provider Demographics
NPI:1700825858
Name:WRIGHT, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WRIGHT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:MATTOX
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:276 N RON MCNAIR BLVD
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:SC
Mailing Address - Zip Code:29560-2462
Mailing Address - Country:US
Mailing Address - Phone:843-394-5471
Mailing Address - Fax:433-945-4598
Practice Address - Street 1:276 N RON MCNAIR BLVD
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:SC
Practice Address - Zip Code:29560-2462
Practice Address - Country:US
Practice Address - Phone:843-394-5471
Practice Address - Fax:433-945-4598
Is Sole Proprietor?:No
Enumeration Date:2006-06-05
Last Update Date:2023-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25363207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC253638Medicaid
SC576007863002OtherBLUE CHOICE OF SC
SC576007863002OtherBCBS OF SC
SCP00352728OtherRR MEDICARE
SC253638Medicaid
SCH384943640Medicare PIN
SCAA05419223Medicare PIN
SCP00352728OtherRR MEDICARE