MEDICARE: LISA JOHNSON KIRK D.O.

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	207Q00000X	Family Medicine Physician	K3775	TX

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1578562146
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA JOHNSON KIRK D.O.

Provider Business Mailing Address
First Line	:	318 RICHLAND WEST CIRCLE
Second Line	:	SUITE A
City	:	WACO
State	:	TX
Zip	:	76712-7919
Country	:	US
Telephone Number	:	254-776-8008
Fax Number	:	254-776-6892

Provider Business Practice Location Address
First Line	:	318 RICHLAND WEST CIRCLE
Second Line	:	SUITE A
City	:	WACO
State	:	TX
Zip	:	76712-7919
Country	:	US
Telephone Number	:	254-776-8008
Fax Number	:	254-776-6892

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

Provider Enumeration Date	:	07/18/2005
Last Update Date	:	07/26/2010

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