Provider Demographics
NPI:1932170263
Name:HENDRICKS, LISA C (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:C
Last Name:HENDRICKS
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 1:1713 HWY 441 N
Mailing Address - Street 2:STE F
Mailing Address - City:OKEECHOBEE
Mailing Address - State:FL
Mailing Address - Zip Code:34972
Mailing Address - Country:US
Mailing Address - Phone:863-763-8000
Mailing Address - Fax:863-763-8212
Practice Address - Street 1:1713 HWY 441 N
Practice Address - Street 2:STE F
Practice Address - City:OKEECHOBEE
Practice Address - State:FL
Practice Address - Zip Code:34972
Practice Address - Country:US
Practice Address - Phone:863-763-8000
Practice Address - Fax:863-763-8212
Is Sole Proprietor?:No
Enumeration Date:2006-01-26
Last Update Date:2020-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01046928A207V00000X
FLME144643207VG0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VG0400XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyGynecology
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200148850Medicaid
IN000000371648OtherANTHEM
P00313457OtherMEDICARE RR
IN200148850Medicaid
IN000000371648OtherANTHEM
P00313457OtherMEDICARE RR