Provider Demographics
NPI:1932100062
Name:LIS, JULIAN GEORGE (MD)
Entity Type:Individual
Prefix:DR
First Name:JULIAN
Middle Name:GEORGE
Last Name:LIS
Suffix:
Gender:M
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4077 5TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92103-2105
Mailing Address - Country:US
Mailing Address - Phone:619-260-7095
Mailing Address - Fax:
Practice Address - Street 1:4077 5TH AVE
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92103-2105
Practice Address - Country:US
Practice Address - Phone:619-260-7095
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2005-08-10
Last Update Date:2008-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAG77160207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G77160Medicaid
CA00G771600Medicaid
CAHG77160Medicare PIN
F77913Medicare UPIN
CA00G77160Medicaid