Healthcare Provider Details

I. General information

NPI: 1528134483
Provider Name (Legal Business Name): LISA LEE MATHIS MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 05/21/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 AMGEN CENTER DR PEDIATRIC CLINIC
THOUSAND OAKS CA
91320-1730
US

IV. Provider business mailing address

500 PINETREE LN
COLFAX CA
95713-9706
US

V. Phone/Fax

Practice location:
  • Phone: 805-279-9046
  • Fax:
Mailing address:
  • Phone: 301-922-5108
  • Fax: 301-796-9744

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD30333
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: