Provider Demographics
NPI:1013962612
Name:CUNNINGHAM, LISA (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:CUNNINGHAM
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 1:2620 TENDERFOOT HILL ST
Mailing Address - Street 2:SUITE 100
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-3981
Mailing Address - Country:US
Mailing Address - Phone:719-576-7006
Mailing Address - Fax:719-576-7981
Practice Address - Street 1:2620 TENDERFOOT HILL ST
Practice Address - Street 2:SUITE 100
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-3981
Practice Address - Country:US
Practice Address - Phone:719-576-7006
Practice Address - Fax:719-576-7981
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO31239208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO01312396Medicaid
CO01312396Medicaid