Provider Demographics
NPI:1962486621
Name:LEWIS, LISA JO (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:JO
Last Name:LEWIS
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 1:2075 NE WYATT CT
Mailing Address - Street 2:
Mailing Address - City:BEND
Mailing Address - State:OR
Mailing Address - Zip Code:97701-7686
Mailing Address - Country:US
Mailing Address - Phone:541-383-3300
Mailing Address - Fax:541-383-4102
Practice Address - Street 1:2075 NE WYATT CT
Practice Address - Street 2:
Practice Address - City:BEND
Practice Address - State:OR
Practice Address - Zip Code:97701-7686
Practice Address - Country:US
Practice Address - Phone:541-383-3300
Practice Address - Fax:541-383-4102
Is Sole Proprietor?:No
Enumeration Date:2005-12-05
Last Update Date:2009-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORMD22810207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OR287076Medicaid
112137Medicare ID - Type Unspecified
OR287076Medicaid