Healthcare Provider Details

I. General information

NPI: 1659489532
Provider Name (Legal Business Name): LISA K LAXSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/29/2006
Last Update Date: 09/26/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5500 S US HIGHWAY 41
TERRE HAUTE IN
47802-4745
US

IV. Provider business mailing address

221 S 6TH ST
TERRE HAUTE IN
47807-4214
US

V. Phone/Fax

Practice location:
  • Phone: 812-232-0564
  • Fax: 812-242-3842
Mailing address:
  • Phone: 812-232-0564
  • Fax: 812-242-3842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number01061236A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: