Healthcare Provider Details

I. General information

NPI: 1306811427
Provider Name (Legal Business Name): LISA M WHITEAKER MD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: LISA MCDONALD MD

II. Dates (important events)

Enumeration Date: 02/22/2006
Last Update Date: 03/31/2021
Certification Date: 03/31/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 PERIMETER PARK DR
COOKEVILLE TN
38501-0922
US

IV. Provider business mailing address

1120 PERIMETER PARK DR
COOKEVILLE TN
38501-0922
US

V. Phone/Fax

Practice location:
  • Phone: 931-528-0002
  • Fax: 931-528-1515
Mailing address:
  • Phone: 931-528-0002
  • Fax: 931-528-1515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD28108
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: