Provider Demographics
NPI:1245289834
Name:MACCORMACK, LISA MARIE (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:MACCORMACK
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1241 W MINERAL AVE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:LITTLETON
Mailing Address - State:CO
Mailing Address - Zip Code:80120-5685
Mailing Address - Country:US
Mailing Address - Phone:303-759-0854
Mailing Address - Fax:303-759-0864
Practice Address - Street 1:4231 W 16TH AVE
Practice Address - Street 2:
Practice Address - City:DENVER
Practice Address - State:CO
Practice Address - Zip Code:80204-1335
Practice Address - Country:US
Practice Address - Phone:303-629-3721
Practice Address - Fax:303-629-2192
Is Sole Proprietor?:No
Enumeration Date:2006-05-09
Last Update Date:2011-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA68040207P00000X
CO36900207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA00A680400Medicaid
COP00808581OtherRR MEDICARE
CO32851871Medicaid
CO32851871Medicaid
CA00A680402Medicare PIN
COP00808581OtherRR MEDICARE
CAH04221Medicare UPIN