Provider Demographics
NPI:1306813134
Name:WILTROUT, LISA M (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:M
Last Name:WILTROUT
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 1:701 CHARLES ST
Mailing Address - Street 2:P.O. BOX 1070
Mailing Address - City:LA PLATA
Mailing Address - State:MD
Mailing Address - Zip Code:20646-5930
Mailing Address - Country:US
Mailing Address - Phone:301-609-4000
Mailing Address - Fax:
Practice Address - Street 1:5 GARRETT AVE
Practice Address - Street 2:CIVISTA MEDICAL CENTER
Practice Address - City:LA PLATA
Practice Address - State:MD
Practice Address - Zip Code:20646-5960
Practice Address - Country:US
Practice Address - Phone:301-609-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-03-01
Last Update Date:2011-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD0057484208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics