Healthcare Provider Details

I. General information

NPI: 1306813134
Provider Name (Legal Business Name): LISA M WILTROUT MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GARRETT AVE CIVISTA MEDICAL CENTER
LA PLATA MD
20646-5960
US

IV. Provider business mailing address

701 CHARLES ST P.O. BOX 1070
LA PLATA MD
20646-5930
US

V. Phone/Fax

Practice location:
  • Phone: 301-609-4000
  • Fax:
Mailing address:
  • Phone: 301-609-4000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberD0057484
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: