Provider Demographics
NPI:1710924386
Name:VERDERBER, LISA
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:VERDERBER
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3612 LAKE AVE
Mailing Address - Street 2:2C
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3612 LAKE AVE
Practice Address - Street 2:2C
Practice Address - City:WILMETTE
Practice Address - State:IL
Practice Address - Zip Code:60091-1000
Practice Address - Country:US
Practice Address - Phone:847-256-2020
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2015-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036101922207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036101922Medicaid
ILL79390Medicare PIN
IL036101922Medicaid
L79390Medicare ID - Type Unspecified