Provider Demographics
NPI:1538102561
Name:ALDERSON, LISA J (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:J
Last Name:ALDERSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:J
Other - Last Name:ALDERSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3635 VISTA AVE
Mailing Address - Street 2:FDT 13TH FLOOR
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-2539
Mailing Address - Country:US
Mailing Address - Phone:314-577-8894
Mailing Address - Fax:314-577-8861
Practice Address - Street 1:3635 VISTA AVE
Practice Address - Street 2:FDT 13TH FLOOR
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-2539
Practice Address - Country:US
Practice Address - Phone:314-577-8894
Practice Address - Fax:314-577-8861
Is Sole Proprietor?:No
Enumeration Date:2006-06-14
Last Update Date:2011-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005029372174400000X, 207RC0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No207RC0000XAllopathic & Osteopathic PhysiciansInternal MedicineCardiovascular Disease
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO122060004Medicare PIN
MOI62145Medicare UPIN