Provider Demographics
NPI:1730444746
Name:DUCKETT, LISA (MD)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:
Last Name:DUCKETT
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:PO BOX 268838
Mailing Address - Street 2:
Mailing Address - City:OKLAHOMA CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73126-8838
Mailing Address - Country:US
Mailing Address - Phone:918-619-4400
Mailing Address - Fax:918-619-4152
Practice Address - Street 1:4444 E 41ST ST
Practice Address - Street 2:3RD FLOOR, STE A
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-2527
Practice Address - Country:US
Practice Address - Phone:918-619-4400
Practice Address - Fax:918-619-4152
Is Sole Proprietor?:No
Enumeration Date:2012-07-06
Last Update Date:2015-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO29711207R00000X
OK15640207R00000X, 207RG0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207RG0300XAllopathic & Osteopathic PhysiciansInternal MedicineGeriatric Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine