Provider Demographics
NPI:1528049178
Name:RENDON, LISA R (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:R
Last Name:RENDON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
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Mailing Address - Street 1:3381 W BAVARIA ST
Mailing Address - Street 2:
Mailing Address - City:EAGLE
Mailing Address - State:ID
Mailing Address - Zip Code:83616-5341
Mailing Address - Country:US
Mailing Address - Phone:208-287-1110
Mailing Address - Fax:208-639-4801
Practice Address - Street 1:3381 W BAVARIA ST
Practice Address - Street 2:
Practice Address - City:EAGLE
Practice Address - State:ID
Practice Address - Zip Code:83616-5341
Practice Address - Country:US
Practice Address - Phone:208-287-1110
Practice Address - Fax:208-639-4801
Is Sole Proprietor?:Yes
Enumeration Date:2005-11-10
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDM9105207XS0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207XS0106XAllopathic & Osteopathic PhysiciansOrthopaedic SurgeryHand Surgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID807057200Medicaid
ID1107435Medicare ID - Type Unspecified
ID807057200Medicaid
ID5625420001Medicare NSC