Provider Demographics
NPI:1932169315
Name:LEE, LISA J (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:LEE
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:PO BOX 5128
Mailing Address - Street 2:
Mailing Address - City:LIMA
Mailing Address - State:OH
Mailing Address - Zip Code:45802-5128
Mailing Address - Country:US
Mailing Address - Phone:419-224-5707
Mailing Address - Fax:419-229-0040
Practice Address - Street 1:730 W MARKET ST
Practice Address - Street 2:
Practice Address - City:LIMA
Practice Address - State:OH
Practice Address - Zip Code:45801-4602
Practice Address - Country:US
Practice Address - Phone:419-227-3361
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-03-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35.0790962085R0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000202854OtherANTHEM BCBS
OH2250282Medicaid
H16703Medicare UPIN
OHLE4049963Medicare ID - Type Unspecified
OHLE4049961Medicare ID - Type Unspecified
OHLE4049962Medicare ID - Type Unspecified