MEDICARE: LISA B FIRESTONE MD, MPH

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	208D00000X	General Practice Physician	01054691A	IN

General Provider Information

NPI Number	:	1134102882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA B FIRESTONE MD, MPH

Provider Business Mailing Address
First Line	:	14336 E MANHEAD LOOKOUT DR
Second Line	:
City	:	VAIL
State	:	AZ
Zip	:	85641-2550
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4175 S ALAMO AVE
Second Line	:	355 AMDS
City	:	DAVIS MONTHAN A F B
State	:	AZ
Zip	:	85707-6097
Country	:	US
Telephone Number	:	520-228-2721
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/28/2005
Last Update Date	:	12/01/2021

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