Healthcare Provider Details

I. General information

NPI: 1013198902
Provider Name (Legal Business Name): LISA DENISE ROARK MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2007
Last Update Date: 11/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 COMMERCE DRIVE
AURORA MO
65605-6260
US

IV. Provider business mailing address

3800 S. NATIONAL AVE STE. 540
SPRINGFIELD MO
65807-5284
US

V. Phone/Fax

Practice location:
  • Phone: 417-269-2400
  • Fax: 417-269-2410
Mailing address:
  • Phone: 417-269-2400
  • Fax: 417-269-2410

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2008017231
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: