Provider Demographics
NPI:1427074541
Name:REINICKE, LISA GARCIA (DPM)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:GARCIA
Last Name:REINICKE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1905 E. HUEBBE PARKWAY
Mailing Address - Street 2:BELOIT HEALTH SYSTEM INC.
Mailing Address - City:BELOIT
Mailing Address - State:WI
Mailing Address - Zip Code:53511-1842
Mailing Address - Country:US
Mailing Address - Phone:608-364-1640
Mailing Address - Fax:608-363-7393
Practice Address - Street 1:1905 E. HUEBBE PARKWAY
Practice Address - Street 2:BELOIT HEALTH SYSTEM INC.
Practice Address - City:BELOIT
Practice Address - State:WI
Practice Address - Zip Code:53511-1842
Practice Address - Country:US
Practice Address - Phone:608-364-1640
Practice Address - Fax:608-363-7393
Is Sole Proprietor?:No
Enumeration Date:2006-07-14
Last Update Date:2011-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI624025213E00000X
IL016-005435213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
REINILISOtherMERCYCARE
WI1427074541Medicaid
REINILISOtherMERCYCARE