=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134786510
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | L.M. DEMIDOWICH PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/21/2019
-----------------------------------------------------
Last Update Date | 05/21/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2286 CROSSWIND DR STE C
-----------------------------------------------------
City | PRESCOTT
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86301-6100
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-464-7742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 27077
-----------------------------------------------------
City | PRESCOTT VALLEY
-----------------------------------------------------
State | AZ
-----------------------------------------------------
Zip | 86312-7077
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 973-464-7742
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | DR. LISA MARIE DEMIDOWICH
-----------------------------------------------------
Credential | DPM
-----------------------------------------------------
Telephone | 973-464-7742
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 213ES0103X
-----------------------------------------------------
Taxonomy Name | Foot & Ankle Surgery Podiatrist
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------