Provider Demographics
NPI:1710081096
Name:SALATA, LISA PETERSON (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:PETERSON
Last Name:SALATA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:MICHELLE
Other - Last Name:PETERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:200 ROCKRIDGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:45322-2728
Mailing Address - Country:US
Mailing Address - Phone:937-274-2117
Mailing Address - Fax:937-274-9809
Practice Address - Street 1:200 ROCKRIDGE RD STE 100
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:OH
Practice Address - Zip Code:45322-2728
Practice Address - Country:US
Practice Address - Phone:937-274-2117
Practice Address - Fax:937-274-9809
Is Sole Proprietor?:No
Enumeration Date:2006-09-08
Last Update Date:2023-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35076934207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2277950Medicaid
OHBP7376177OtherDEA NUMBER
H49898Medicare UPIN
OH2277950Medicaid