Provider Demographics
NPI:1912995259
Name:CLUNIE, LISA FAYE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:FAYE
Last Name:CLUNIE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:F
Other - Last Name:KELLUM
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 38
Mailing Address - Street 2:
Mailing Address - City:CORYDON
Mailing Address - State:IN
Mailing Address - Zip Code:47112-0038
Mailing Address - Country:US
Mailing Address - Phone:812-738-8763
Mailing Address - Fax:812-738-7833
Practice Address - Street 1:1995 EDSEL LN NW
Practice Address - Street 2:SUITE 3
Practice Address - City:CORYDON
Practice Address - State:IN
Practice Address - Zip Code:47112-3008
Practice Address - Country:US
Practice Address - Phone:812-738-4915
Practice Address - Fax:812-734-1365
Is Sole Proprietor?:No
Enumeration Date:2005-10-11
Last Update Date:2022-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01058900A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200487550Medicaid
IN000000345157OtherANTHEM
IN000000345157OtherANTHEM
IN940190DDDDMedicare PIN