Provider Demographics
NPI:1891815320
Name:KEARNS, LISA MARIE ROSHETSKY (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:MARIE ROSHETSKY
Last Name:KEARNS
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 1:660 LONDON AVE STE A
Mailing Address - Street 2:
Mailing Address - City:MARYSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:43040-1515
Mailing Address - Country:US
Mailing Address - Phone:937-642-1550
Mailing Address - Fax:
Practice Address - Street 1:660 LONDON AVE STE A
Practice Address - Street 2:
Practice Address - City:MARYSVILLE
Practice Address - State:OH
Practice Address - Zip Code:43040-1515
Practice Address - Country:US
Practice Address - Phone:937-642-1550
Practice Address - Fax:937-578-2821
Is Sole Proprietor?:No
Enumeration Date:2007-03-29
Last Update Date:2023-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCMD040679207R00000X
OH35093936207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2966401Medicaid