Provider Demographics
NPI:1467455808
Name:WATERMAN, LISA RENEE (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:RENEE
Last Name:WATERMAN
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 1:5501 WILLOW CREEK DR STE 203
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-8708
Mailing Address - Country:US
Mailing Address - Phone:405-413-4351
Mailing Address - Fax:479-757-2942
Practice Address - Street 1:5501 WILLOW CREEK DR STE 203
Practice Address - Street 2:
Practice Address - City:SPRINGDALE
Practice Address - State:AR
Practice Address - Zip Code:72762-8708
Practice Address - Country:US
Practice Address - Phone:479-757-5552
Practice Address - Fax:479-757-2942
Is Sole Proprietor?:No
Enumeration Date:2005-05-31
Last Update Date:2025-02-14
Deactivation Date:2006-03-20
Deactivation Code:
Reactivation Date:2006-03-24
Provider Licenses
StateLicense IDTaxonomies
ARE-18839207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100148640AMedicaid
OK$$$$$$$$$Medicare PIN
OKH45258Medicare UPIN