Healthcare Provider Details

I. General information

NPI: 1689636904
Provider Name (Legal Business Name): LISA MARIE OLDHAM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/03/2006
Last Update Date: 10/04/2021
Certification Date: 10/04/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7447 W TALCOTT AVE STE 454
CHICAGO IL
60631-3715
US

IV. Provider business mailing address

7447 W TALCOTT AVE STE 454
CHICAGO IL
60631-3715
US

V. Phone/Fax

Practice location:
  • Phone: 773-631-5767
  • Fax:
Mailing address:
  • Phone: 773-631-5767
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207VG0400X
TaxonomyGynecology Physician
License Number036-105494
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: