MEDICARE: LISA M WILTROUT MD

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	208000000X	Pediatrics Physician	D0057484	MD

General Provider Information

NPI Number	:	1306813134
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA M WILTROUT MD

Provider Business Mailing Address
First Line	:	701 CHARLES ST
Second Line	:	P.O. BOX 1070
City	:	LA PLATA
State	:	MD
Zip	:	20646-5930
Country	:	US
Telephone Number	:	301-609-4000
Fax Number	:

Provider Business Practice Location Address
First Line	:	5 GARRETT AVE
Second Line	:	CIVISTA MEDICAL CENTER
City	:	LA PLATA
State	:	MD
Zip	:	20646-5960
Country	:	US
Telephone Number	:	301-609-4000
Fax Number	:

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	04/21/2011

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