Provider Demographics
NPI:1659489532
Name:LAXSON, LISA K (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:K
Last Name:LAXSON
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 1:221 S 6TH ST
Mailing Address - Street 2:
Mailing Address - City:TERRE HAUTE
Mailing Address - State:IN
Mailing Address - Zip Code:47807-4214
Mailing Address - Country:US
Mailing Address - Phone:812-232-0564
Mailing Address - Fax:812-242-3842
Practice Address - Street 1:5500 S US HIGHWAY 41
Practice Address - Street 2:
Practice Address - City:TERRE HAUTE
Practice Address - State:IN
Practice Address - Zip Code:47802-4745
Practice Address - Country:US
Practice Address - Phone:812-232-0564
Practice Address - Fax:812-242-3842
Is Sole Proprietor?:No
Enumeration Date:2006-08-29
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01061236A207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
P00315179OtherRAILROAD MCARE PALAMETTO
351904269221OtherCARESOURCE MEDICAID
7014223OtherCIGNA
740329OtherHEALTHLINK
000000384966AOtherANTHEM
7411388OtherAETNA
IN192770GGGGMedicare PIN
000000384966AOtherANTHEM
IN859910NNNNMedicare PIN