=====================================================
General NPI Number Information
=====================================================
NPI Number | 1528134483
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LISA LEE MATHIS MD
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/24/2006
-----------------------------------------------------
Last Update Date | 05/21/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1 AMGEN CENTER DR PEDIATRIC CLINIC
-----------------------------------------------------
City | THOUSAND OAKS
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91320-1730
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 805-279-9046
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 500 PINETREE LN
-----------------------------------------------------
City | COLFAX
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 95713-9706
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-922-5108
-----------------------------------------------------
Fax | 301-796-9744
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208000000X
-----------------------------------------------------
Taxonomy Name | Pediatrics Physician
-----------------------------------------------------
License Number | MD30333
-----------------------------------------------------
License Number State | DC
-----------------------------------------------------