Provider Demographics
NPI:1780601351
Name:LISONI, KATHERINE (MD)
Entity type:Individual
Prefix:
First Name:KATHERINE
Middle Name:
Last Name:LISONI
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 1:2401 VALLEY DR
Mailing Address - Street 2:
Mailing Address - City:VALPARAISO
Mailing Address - State:IN
Mailing Address - Zip Code:46383-2520
Mailing Address - Country:US
Mailing Address - Phone:219-413-5100
Mailing Address - Fax:219-465-9502
Practice Address - Street 1:420 W 4TH ST
Practice Address - Street 2:
Practice Address - City:MISHAWAKA
Practice Address - State:IN
Practice Address - Zip Code:46544-1948
Practice Address - Country:US
Practice Address - Phone:574-307-7673
Practice Address - Fax:574-307-7692
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2021-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN11011690207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200844990Medicaid
IN000000580326OtherBCBS
738460SSSSMedicare PIN
239010MMedicare PIN
168060FFMedicare PIN