Provider Demographics
NPI:1780681015
Name:COX, LISA GHOLSTON (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:GHOLSTON
Last Name:COX
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:REGINA
Other - Last Name:GHOLSTON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:2002 N CEDAR ST STE B
Mailing Address - Street 2:
Mailing Address - City:LUMBERTON
Mailing Address - State:NC
Mailing Address - Zip Code:28358-3926
Mailing Address - Country:US
Mailing Address - Phone:910-272-3048
Mailing Address - Fax:910-738-3764
Practice Address - Street 1:395 W 27TH ST
Practice Address - Street 2:
Practice Address - City:LUMBERTON
Practice Address - State:NC
Practice Address - Zip Code:28358-3018
Practice Address - Country:US
Practice Address - Phone:910-739-7551
Practice Address - Fax:910-739-2332
Is Sole Proprietor?:Yes
Enumeration Date:2005-07-01
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000036628207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8935191Medicaid
NC8935191Medicaid
F90541Medicare UPIN