Provider Demographics
NPI:1699717595
Name:TODD, LISA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:TODD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:LISA
Other - Middle Name:MARIE
Other - Last Name:BENNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 1779
Mailing Address - Street 2:
Mailing Address - City:BOZEMAN
Mailing Address - State:MT
Mailing Address - Zip Code:59771-1779
Mailing Address - Country:US
Mailing Address - Phone:406-595-0852
Mailing Address - Fax:
Practice Address - Street 1:777 E MAIN ST
Practice Address - Street 2:SUITE 101
Practice Address - City:BOZEMAN
Practice Address - State:MT
Practice Address - Zip Code:59715-3808
Practice Address - Country:US
Practice Address - Phone:406-595-0852
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-12
Last Update Date:2017-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTMT1136208100000X
MT11366208100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208100000XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA8460164Medicaid
MT8860422OtherMEDICARE
WA8460164Medicaid
WA8874972Medicare PIN