Provider Demographics
NPI:1184603193
Name:DAVIDSON, LISA R (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:DAVIDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 8674
Mailing Address - Street 2:1230 E MAIN ST MANKATO CLINIC LTD
Mailing Address - City:MANKATO
Mailing Address - State:MN
Mailing Address - Zip Code:56002-8674
Mailing Address - Country:US
Mailing Address - Phone:507-625-1811
Mailing Address - Fax:
Practice Address - Street 1:1230 E MAIN STREET
Practice Address - Street 2:MANKATO CLINIC AT MAIN STREET
Practice Address - City:MANKATO
Practice Address - State:MN
Practice Address - Zip Code:56002-8674
Practice Address - Country:US
Practice Address - Phone:507-625-1811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-01-10
Last Update Date:2020-07-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
MN434962084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN1328361OtherAMERICAS PPO
410849339 56001 C181OtherCHAMPUS
MN0500173OtherMEDICA
MN151694OtherUCARE
MN071645600Medicaid
IA0947127OtherMEDICAID
MN45D61DAOtherBCBS
130024186OtherRR MEDICARE
MNHP32997OtherHEALTH PARTNERS
MNNA2951027572OtherPREFERRED ONE
MN130000993Medicare ID - Type Unspecified
MNHP32997OtherHEALTH PARTNERS