Provider Demographics
NPI:1801825914
Name:HOUCHIN, LISA DURHAM (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:DURHAM
Last Name:HOUCHIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4501 CAMERON VALLEY PKWY
Practice Address - Street 2:STE 200
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-4297
Practice Address - Country:US
Practice Address - Phone:704-512-3636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-01
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC9901206207RE0101X, 208000000X, 2080P0205X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2080P0205XAllopathic & Osteopathic PhysiciansPediatricsPediatric Endocrinology
No207RE0101XAllopathic & Osteopathic PhysiciansInternal MedicineEndocrinology, Diabetes & Metabolism
No208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCN01209Medicaid
NC1801825914Medicaid
NC891235VMedicaid
NC2279764AMedicare PIN
NCH03627Medicare UPIN