MEDICARE: DR. LISA JO SHIVES M.D.

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	207RS0012X	Sleep Medicine (Internal Medicine) Physician	C131956	CA

General Provider Information

NPI Number	:	1740322825
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. LISA JO SHIVES M.D.

Provider Business Mailing Address
First Line	:	1853 LYNDON RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1644
Country	:	US
Telephone Number	:	619-944-7532
Fax Number	:	619-566-4432

Provider Business Practice Location Address
First Line	:	1853 LYNDON RD
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92103-1644
Country	:	US
Telephone Number	:	619-944-7532
Fax Number	:	619-566-4432

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

Provider Enumeration Date	:	02/13/2007
Last Update Date	:	12/04/2020

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