Provider Demographics
NPI:1528134483
Name:MATHIS, LISA LEE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:LEE
Last Name:MATHIS
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
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Other - Credentials:
Mailing Address - Street 1:500 PINETREE LN
Mailing Address - Street 2:
Mailing Address - City:COLFAX
Mailing Address - State:CA
Mailing Address - Zip Code:95713-9706
Mailing Address - Country:US
Mailing Address - Phone:301-922-5108
Mailing Address - Fax:301-796-9744
Practice Address - Street 1:1 AMGEN CENTER DR
Practice Address - Street 2:PEDIATRIC CLINIC
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91320-1730
Practice Address - Country:US
Practice Address - Phone:805-279-9046
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-24
Last Update Date:2013-05-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
DCMD30333208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCMD30333OtherMEDICAL LICENSE