Provider Demographics
NPI:1821046202
Name:MARTIN, LISA LYNN (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:LYNN
Last Name:MARTIN
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:LYNN
Other - Last Name:GREEN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1542 S BLOOMINGTON ST
Mailing Address - Street 2:SUITE 1300
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-2212
Mailing Address - Country:US
Mailing Address - Phone:765-658-2700
Mailing Address - Fax:765-658-2703
Practice Address - Street 1:1542 S BLOOMINGTON ST
Practice Address - Street 2:SUITE 1300
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2212
Practice Address - Country:US
Practice Address - Phone:765-658-2700
Practice Address - Fax:765-658-2703
Is Sole Proprietor?:No
Enumeration Date:2006-05-05
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01056225A207RA0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RA0000XAllopathic & Osteopathic PhysiciansInternal MedicineAdolescent Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN3422489001OtherCIGNA INS.
IN200380830Medicaid
IN94041016Medicare ID - Type Unspecified
INH74273Medicare UPIN