Provider Demographics
NPI:1821021296
Name:DWELLE, LISA M (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:DWELLE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ANNETTE
Other - Last Name:MILLS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1900 GARDEN ROAD #100
Mailing Address - Street 2:
Mailing Address - City:MONTEREY
Mailing Address - State:CA
Mailing Address - Zip Code:93940
Mailing Address - Country:US
Mailing Address - Phone:831-375-4945
Mailing Address - Fax:
Practice Address - Street 1:1900 GARDEN ROAD #100
Practice Address - Street 2:
Practice Address - City:MONTEREY
Practice Address - State:CA
Practice Address - Zip Code:93940
Practice Address - Country:US
Practice Address - Phone:831-375-4945
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-09
Last Update Date:2015-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA77234207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A772341OtherMEDICARE
CAH80596Medicare UPIN