=====================================================
General NPI Number Information
=====================================================
NPI Number | 1982843769
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LISA MEDWEDEFF M.D. PA
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/18/2009
-----------------------------------------------------
Last Update Date | 07/10/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5425 W SPRING CREEK PKWY STE 210
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-608-3333
-----------------------------------------------------
Fax | 972-473-7333
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5425 W SPRING CREEK PKWY STE 210
-----------------------------------------------------
City | PLANO
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75024-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-608-3333
-----------------------------------------------------
Fax | 972-473-7333
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PHYSICIAN/OWNER
-----------------------------------------------------
Name | LISA E MEDWEDEFF
-----------------------------------------------------
Credential | MD PA
-----------------------------------------------------
Telephone | 972-608-3333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 174400000X
-----------------------------------------------------
Taxonomy Name | Specialist
-----------------------------------------------------
License Number | K1257
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------