Provider Demographics
NPI:1760459887
Name:KEITHLEY, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KEITHLEY
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:8186 LARK BROWN RD STE 203
Mailing Address - Street 2:
Mailing Address - City:ELKRIDGE
Mailing Address - State:MD
Mailing Address - Zip Code:21075-6434
Mailing Address - Country:US
Mailing Address - Phone:410-799-8931
Mailing Address - Fax:410-799-8668
Practice Address - Street 1:8186 LARK BROWN RD STE 203
Practice Address - Street 2:
Practice Address - City:ELKRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21075-6434
Practice Address - Country:US
Practice Address - Phone:410-799-8931
Practice Address - Fax:441-799-8668
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-07
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0056088207Q00000X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD011989OtherJHHC PROVIDER NUMBER
MD7605-0102OtherCAREFIRST BLUECHOICE
MD697600000Medicaid
MD8196530OtherMAMSI PRIMARY CARE
MDP00726152OtherRAILROAD MEDICARE
MD6881582OtherAETNA CAPITATED
MD2196530OtherMAMSI SPECIALIST
MD606832-05OtherCAREFIRST MD RENDERING
MD7480124OtherAETNA FEE FOR SERVICE
MD2026499OtherUHC PROVIDER NUMBER
MDP18514OtherCAREFIRST MPOS
MDP18514OtherCAREFIRST MPOS
MD697600000Medicaid