Provider Demographics
NPI:1740398593
Name:ETZWILER, LISA S (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:S
Last Name:ETZWILER
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Gender:F
Credentials:MD
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Mailing Address - Street 1:16522 BAXTER FOREST RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:CHESTERFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:63005-4661
Mailing Address - Country:US
Mailing Address - Phone:636-519-1655
Mailing Address - Fax:636-536-4973
Practice Address - Street 1:621 S NEW BALLAS RD
Practice Address - Street 2:ST. JOHN'S MERCY MEDICAL CENTER, SUITE 6006, TOWER B
Practice Address - City:CREVE COEUR
Practice Address - State:MO
Practice Address - Zip Code:63141-8232
Practice Address - Country:US
Practice Address - Phone:314-251-6299
Practice Address - Fax:314-251-4450
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
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Provider Licenses
StateLicense IDTaxonomies
MO102051207PP0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PP0204XAllopathic & Osteopathic PhysiciansEmergency MedicinePediatric Emergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MOEO1258Medicare UPIN