MEDICARE: DR. LISA DIANE DAVIDSON D.O.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207Q00000X	Family Medicine Physician	37134	CO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	141898808	OTHER	CO	TAX ID

General Provider Information

NPI Number	:	1235185406
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA DIANE DAVIDSON D.O.

Provider Business Mailing Address
First Line	:	2373 CENTRAL PARK BLVD UNIT 205
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80238-2300
Country	:	US
Telephone Number	:	303-377-2494
Fax Number	:	303-377-2548

Provider Business Practice Location Address
First Line	:	2373 CENTRAL PARK BLVD UNIT 205
Second Line	:
City	:	DENVER
State	:	CO
Zip	:	80238-2300
Country	:	US
Telephone Number	:	303-377-2494
Fax Number	:	303-377-2548

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/26/2006
Last Update Date	:	04/02/2014

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