Provider Demographics
NPI:1780730317
Name:ROTHGERY, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:ROTHGERY
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 1:300 S JACKSON ST
Mailing Address - Street 2:SUITE 340
Mailing Address - City:DENVER
Mailing Address - State:CO
Mailing Address - Zip Code:80209-3176
Mailing Address - Country:US
Mailing Address - Phone:303-316-0416
Mailing Address - Fax:303-316-0421
Practice Address - Street 1:300 S JACKSON ST
Practice Address - Street 2:SUITE 340
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80209-3176
Practice Address - Country:US
Practice Address - Phone:303-316-0416
Practice Address - Fax:303-316-0421
Is Sole Proprietor?:No
Enumeration Date:2007-01-26
Last Update Date:2016-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COTL-1877390200000X
CODR.0046058207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO07220511Medicaid
COCOA103208Medicare PIN