Provider Demographics
NPI:1336394881
Name:CHUN, LISA R (DO)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:R
Last Name:CHUN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6626 E 75TH ST
Mailing Address - Street 2:STE 500
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46250-2805
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 COLD SPRING RD
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46222-1960
Practice Address - Country:US
Practice Address - Phone:317-955-6296
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-11-25
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIDOS 918204D00000X
IN02004296A204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
235572OtherHMSA LEGACY
IN201207980Medicaid
INP01424287OtherRAIL ROAD PTAN
55122Medicare UPIN
IN201207980Medicaid