Provider Demographics
NPI:1548241862
Name:DANNEMILLER, LISA A (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:A
Last Name:DANNEMILLER
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1402 BOETTLER RD STE C
Mailing Address - Street 2:
Mailing Address - City:UNIONTOWN
Mailing Address - State:OH
Mailing Address - Zip Code:44685-9584
Mailing Address - Country:US
Mailing Address - Phone:330-899-0103
Mailing Address - Fax:330-899-0268
Practice Address - Street 1:1402 BOETTLER RD STE C
Practice Address - Street 2:
Practice Address - City:UNIONTOWN
Practice Address - State:OH
Practice Address - Zip Code:44685-9584
Practice Address - Country:US
Practice Address - Phone:330-899-0103
Practice Address - Fax:330-899-0268
Is Sole Proprietor?:No
Enumeration Date:2005-11-14
Last Update Date:2011-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH35067149D207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0786884OtherMEDICARE ID
OH2157357Medicaid
OH0786884OtherMEDICARE ID