Provider Demographics
NPI:1356397913
Name:LISA C OVERTON
Entity type:Organization
Organization Name:LISA C OVERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:CAROL
Authorized Official - Last Name:OVERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:215-548-2010
Mailing Address - Street 1:1940 E WALNUT LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19138-1312
Mailing Address - Country:US
Mailing Address - Phone:215-548-2113
Mailing Address - Fax:215-548-3009
Practice Address - Street 1:1940 E WALNUT LN
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19138-1312
Practice Address - Country:US
Practice Address - Phone:215-548-2113
Practice Address - Fax:215-548-3009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2011-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASC004492L213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA2134337000Other10 DIGIT IBC HMO ID
PA10741OtherELDER HEALTH ID
PA5403600001OtherDMERC SUPPLIER ID
PA001444333OtherHIGH MARK BLUE SHIELD ID
PA0018442730002Medicaid
PAP00041340OtherMEDICARE RAILROAD ID
PAP00041340OtherMEDICARE RAILROAD ID
PA5403600001OtherDMERC SUPPLIER ID