Provider Demographics
NPI:1902039241
Name:LISA CORSTVET MD PLLC
Entity Type:Organization
Organization Name:LISA CORSTVET MD PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING COORDINATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHERI
Authorized Official - Middle Name:
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:405-418-4800
Mailing Address - Street 1:PO BOX 975008
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75397-5008
Mailing Address - Country:US
Mailing Address - Phone:405-418-4800
Mailing Address - Fax:405-418-4820
Practice Address - Street 1:4317 W MEMORIAL RD
Practice Address - Street 2:
Practice Address - City:OKLAHOMA CITY
Practice Address - State:OK
Practice Address - Zip Code:73134-1720
Practice Address - Country:US
Practice Address - Phone:405-418-4800
Practice Address - Fax:405-418-4820
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-09-03
Last Update Date:2020-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK16541207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiologyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200257060AMedicaid
OK614474300OtherDOL
OK=========001OtherBCBS
OK200257060AMedicaid