Provider Demographics
NPI:1821051822
Name:FORREST, LISA WAGNER (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:WAGNER
Last Name:FORREST
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 1:2752 CLOYSTER CT
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49008-2339
Mailing Address - Country:US
Mailing Address - Phone:269-492-0240
Mailing Address - Fax:
Practice Address - Street 1:1850 WHITES RD
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-4801
Practice Address - Country:US
Practice Address - Phone:269-343-3900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-10
Last Update Date:2009-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301057603207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0C910950OtherBCBSM
MI1821051822Medicaid