Provider Demographics
NPI:1063619013
Name:BODON, LISA MONIQUE (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MONIQUE
Last Name:BODON
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 1:555 E TACHEVAH DR
Mailing Address - Street 2:SUITE 2W #201
Mailing Address - City:PALM SPRINGS
Mailing Address - State:CA
Mailing Address - Zip Code:92262-5750
Mailing Address - Country:US
Mailing Address - Phone:760-323-9309
Mailing Address - Fax:760-610-8995
Practice Address - Street 1:555 E TACHEVAH DR
Practice Address - Street 2:SUITE 2W #201
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5750
Practice Address - Country:US
Practice Address - Phone:760-323-9309
Practice Address - Fax:760-610-8995
Is Sole Proprietor?:No
Enumeration Date:2007-07-02
Last Update Date:2012-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA97869207V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A978690Medicaid
CAGR0042690Medicaid
CAZZZ50078YOtherBLUE SHIELD
CAZZZ89650ZMedicare PIN
CAZZZ50078YOtherBLUE SHIELD