Provider Demographics
NPI:1669783304
Name:TOWN, LISHA (MD)
Entity type:Individual
Prefix:
First Name:LISHA
Middle Name:
Last Name:TOWN
Suffix:
Gender:
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:PO BOX 213
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:46536-0213
Mailing Address - Country:US
Mailing Address - Phone:574-213-5042
Mailing Address - Fax:781-883-8102
Practice Address - Street 1:111 S MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:IN
Practice Address - Zip Code:46536
Practice Address - Country:US
Practice Address - Phone:574-213-5042
Practice Address - Fax:781-883-8102
Is Sole Proprietor?:No
Enumeration Date:2010-06-28
Last Update Date:2025-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01070454A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000832093OtherBCBS
IN000000832093OtherBCBS
IN187810001Medicare PIN
ININ1133020Medicare PIN