Provider Demographics
NPI:1588694707
Name:OLDSON, LISA (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:
Last Name:OLDSON
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 1:615 GREGORY AVE
Mailing Address - Street 2:
Mailing Address - City:WILMETTE
Mailing Address - State:IL
Mailing Address - Zip Code:60091-3419
Mailing Address - Country:US
Mailing Address - Phone:773-814-8598
Mailing Address - Fax:
Practice Address - Street 1:5250 OLD ORCHARD RD STE 300
Practice Address - Street 2:
Practice Address - City:SKOKIE
Practice Address - State:IL
Practice Address - Zip Code:60077-4462
Practice Address - Country:US
Practice Address - Phone:773-814-8598
Practice Address - Fax:847-983-3401
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-04
Last Update Date:2019-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036-094872207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036-094872Medicaid
IL036-094872Medicaid