Basic Information
| Provider Information | |||||||||
| NPI: | 1053328989 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DODSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | GRILL | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2720 PLAZA DR | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472472 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2720 PLAZA DR | ||||||||
| Address2: | SUITE 1100 | ||||||||
| City: | WAUSAU | ||||||||
| State: | WI | ||||||||
| PostalCode: | 544014158 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7158472472 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/02/2006 | ||||||||
| LastUpdateDate: | 12/01/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/01/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 63624 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 024096 | 05 | OR | MEDICAID |