Provider Demographics
NPI:1891707832
Name:KLOCK, LISA (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:KLOCK
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2508 E UNIVERSITY AVE
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50317-5313
Mailing Address - Country:US
Mailing Address - Phone:515-282-3278
Mailing Address - Fax:515-282-5354
Practice Address - Street 1:2508 E UNIVERSITY AVE
Practice Address - Street 2:BROADLAWNS EAST UNIVERSITY CLINIC
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50317-5313
Practice Address - Country:US
Practice Address - Phone:515-282-3278
Practice Address - Fax:515-282-5354
Is Sole Proprietor?:No
Enumeration Date:2006-08-11
Last Update Date:2017-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA02866207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA0139667Medicaid
IA54344Medicare ID - Type Unspecified
IAF70389Medicare UPIN