Provider Demographics
NPI:1366517666
Name:MILDER, LISA L (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:L
Last Name:MILDER
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2740 S COUNTY TRL
Mailing Address - Street 2:SUITE 2
Mailing Address - City:EAST GREENWICH
Mailing Address - State:RI
Mailing Address - Zip Code:02818-1730
Mailing Address - Country:US
Mailing Address - Phone:401-886-7030
Mailing Address - Fax:
Practice Address - Street 1:2740 S COUNTY TRL
Practice Address - Street 2:
Practice Address - City:EAST GREENWICH
Practice Address - State:RI
Practice Address - Zip Code:02818-1730
Practice Address - Country:US
Practice Address - Phone:401-886-7030
Practice Address - Fax:401-886-7031
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-21
Last Update Date:2013-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIDO 00423204D00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes204D00000XAllopathic & Osteopathic PhysiciansNeuromusculoskeletal Medicine & OMM
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI0101654OtherUNITED HEALTH CARE
RI759423Medicare UPIN
RI0101654OtherUNITED HEALTH CARE
RI3099-5Medicare UPIN
RI128003099Medicare ID - Type Unspecified