Provider Demographics
NPI:1952486094
Name:CLEMENT, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CLEMENT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2030 VIBORG RD
Mailing Address - Street 2:STE 102
Mailing Address - City:SOLVANG
Mailing Address - State:CA
Mailing Address - Zip Code:93463-3224
Mailing Address - Country:US
Mailing Address - Phone:805-686-5533
Mailing Address - Fax:805-686-9977
Practice Address - Street 1:2030 VIBORG RD
Practice Address - Street 2:STE 102
Practice Address - City:SOLVANG
Practice Address - State:CA
Practice Address - Zip Code:93463-3224
Practice Address - Country:US
Practice Address - Phone:805-686-5533
Practice Address - Fax:805-686-9977
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-26
Last Update Date:2012-07-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CAG072630207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00G726300Medicaid
CAG72630Medicare PIN
CA00G726300Medicaid