Provider Demographics
NPI:1124080544
Name:WARREN, LISA (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:WARREN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:795 E. SECOND STREET
Mailing Address - Street 2:SUITE 5
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-2007
Mailing Address - Country:US
Mailing Address - Phone:909-865-2565
Mailing Address - Fax:909-865-2599
Practice Address - Street 1:795 E. SECOND STREET
Practice Address - Street 2:SUITE 5
Practice Address - City:POMONA
Practice Address - State:CA
Practice Address - Zip Code:91766-2007
Practice Address - Country:US
Practice Address - Phone:909-865-2565
Practice Address - Fax:909-865-2599
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2011-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL7596208000000X
CA20A11796208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1656936-01OtherCSHCN
TX1656936-01Medicaid
CA20A11796OtherCA STATE LIC
TX8M1115OtherBLUE SHIELD
TX8M1115OtherBLUE SHIELD
TX1656936-01Medicaid