Provider Demographics
NPI:1487604526
Name:KOKONTIS, LISA MARY (MD)
Entity type:Individual
Prefix:MRS
First Name:LISA
Middle Name:MARY
Last Name:KOKONTIS
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 1:130 2ND STREET
Mailing Address - Street 2:WEST PAVILION 2ND FLOOR THE NEUROSCIENCE GROUP OF NE WI
Mailing Address - City:NEENAH
Mailing Address - State:WI
Mailing Address - Zip Code:54956-2883
Mailing Address - Country:US
Mailing Address - Phone:920-725-9373
Mailing Address - Fax:920-720-7392
Practice Address - Street 1:130 2ND STREET
Practice Address - Street 2:WEST PAVILION 2ND FLOOR THE NEUROSCIENCE GROUP OF NE WI
Practice Address - City:NEENAH
Practice Address - State:WI
Practice Address - Zip Code:54956-2883
Practice Address - Country:US
Practice Address - Phone:920-725-9373
Practice Address - Fax:920-720-7392
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI404642084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI32494700Medicaid
WI32494700Medicaid