Provider Demographics
NPI:1154377042
Name:CRAMER, LISA T (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:T
Last Name:CRAMER
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 11512
Mailing Address - Street 2:
Mailing Address - City:PUEBLO
Mailing Address - State:CO
Mailing Address - Zip Code:81001-0512
Mailing Address - Country:US
Mailing Address - Phone:719-542-2167
Mailing Address - Fax:719-542-0320
Practice Address - Street 1:1619 N GREENWOOD ST
Practice Address - Street 2:SUITE 103
Practice Address - City:PUEBLO
Practice Address - State:CO
Practice Address - Zip Code:81003-2644
Practice Address - Country:US
Practice Address - Phone:719-542-2167
Practice Address - Fax:719-542-0320
Is Sole Proprietor?:No
Enumeration Date:2006-05-25
Last Update Date:2008-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO398942085R0202X, 2085R0204X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2085R0202XAllopathic & Osteopathic PhysiciansRadiologyDiagnostic Radiology
No2085R0204XAllopathic & Osteopathic PhysiciansRadiologyVascular & Interventional Radiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO77659732Medicaid
CO77659732Medicaid
COC455888Medicare PIN
COC438568Medicare PIN
COC438578Medicare PIN