Provider Demographics
NPI:1720059603
Name:GRAHAM, LISA S (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:S
Last Name:GRAHAM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:S
Other - Last Name:MACDONALD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5007 MATTERHORN DRIVE
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:MN
Mailing Address - Zip Code:55811-3812
Mailing Address - Country:US
Mailing Address - Phone:218-720-3553
Mailing Address - Fax:218-786-9375
Practice Address - Street 1:5007 MATTERHORN DRIVE
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:MN
Practice Address - Zip Code:55811-3812
Practice Address - Country:US
Practice Address - Phone:218-720-3553
Practice Address - Fax:218-786-9375
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2010-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI42312207W00000X
WI42312-20207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI33333100Medicaid
MN837658100Medicaid
WI000452485Medicare ID - Type Unspecified
G35008Medicare UPIN
WI33333100Medicaid
WIG35008Medicare UPIN