Provider Demographics
NPI:1306811427
Name:WHITEAKER, LISA M (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WHITEAKER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:MCDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1120 PERIMETER PARK DR
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-0922
Mailing Address - Country:US
Mailing Address - Phone:931-528-0002
Mailing Address - Fax:931-528-1515
Practice Address - Street 1:1120 PERIMETER PARK DR
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-0922
Practice Address - Country:US
Practice Address - Phone:931-528-0002
Practice Address - Fax:931-528-1515
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-22
Last Update Date:2021-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNMD28108207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNG50289Medicare UPIN
TN3839185Medicare ID - Type UnspecifiedMEDICARE NUMBER