Provider Demographics
NPI:1992918726
Name:RICHARDSON, LISA K (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:RICHARDSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1040 SIERRA DR
Mailing Address - Street 2:SUITE 400
Mailing Address - City:GREENWOOD
Mailing Address - State:IN
Mailing Address - Zip Code:46143-7240
Mailing Address - Country:US
Mailing Address - Phone:317-865-8988
Mailing Address - Fax:317-859-8590
Practice Address - Street 1:18636 DIXIE HWY
Practice Address - Street 2:
Practice Address - City:HOMEWOOD
Practice Address - State:IL
Practice Address - Zip Code:60430-3741
Practice Address - Country:US
Practice Address - Phone:708-647-0571
Practice Address - Fax:708-647-0676
Is Sole Proprietor?:No
Enumeration Date:2007-05-08
Last Update Date:2018-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
IL036117734207Q00000X
IN01068767A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN20999260Medicaid
IN200999260Medicaid