Healthcare Provider Details

I. General information

NPI: 1275743684
Provider Name (Legal Business Name): LISA D ORTIZ M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/23/2007
Last Update Date: 04/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 J T STITES BLVD REDBIRD SMITH HEALTH CENTER
SALLISAW OK
74955-9302
US

IV. Provider business mailing address

1483 DEER RUN DR
FORT GIBSON OK
74434-9351
US

V. Phone/Fax

Practice location:
  • Phone: 918-775-9159
  • Fax: 918-775-6469
Mailing address:
  • Phone: 918-478-2267
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number25970
License Number StateOK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: