Provider Demographics
NPI:1780754713
Name:LIS, ROBERT JAMES (DO)
Entity type:Individual
Prefix:
First Name:ROBERT
Middle Name:JAMES
Last Name:LIS
Suffix:
Gender:M
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:PO BOX 847969
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90084-7969
Mailing Address - Country:US
Mailing Address - Phone:626-795-6596
Mailing Address - Fax:
Practice Address - Street 1:35800 BOB HOPE DR
Practice Address - Street 2:100
Practice Address - City:RANCHO MIRAGE
Practice Address - State:CA
Practice Address - Zip Code:92270-1739
Practice Address - Country:US
Practice Address - Phone:562-407-2080
Practice Address - Fax:562-407-2082
Is Sole Proprietor?:No
Enumeration Date:2006-11-08
Last Update Date:2020-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A6953207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA020A69530Medicare PIN