Provider Demographics
NPI:1841380375
Name:SULLIVAN, LISA C (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:C
Last Name:SULLIVAN
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 1:421 SW OAK ST
Mailing Address - Street 2:STE 210
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97204-1817
Mailing Address - Country:US
Mailing Address - Phone:503-988-7468
Mailing Address - Fax:503-988-7468
Practice Address - Street 1:4950 SE ROETHE RD
Practice Address - Street 2:
Practice Address - City:MILWAUKIE
Practice Address - State:OR
Practice Address - Zip Code:97267-5746
Practice Address - Country:US
Practice Address - Phone:503-722-6858
Practice Address - Fax:503-722-6826
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2019-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD24619208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR096511Medicaid
OR240558Medicaid
OR22959Medicaid
OR240558Medicaid