Basic Information
| Provider Information | |||||||||
| NPI: | 1184603193 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DAVIDSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | R | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 8674 | ||||||||
| Address2: | 1230 E MAIN ST MANKATO CLINIC LTD | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1230 E MAIN STREET | ||||||||
| Address2: | MANKATO CLINIC AT MAIN STREET | ||||||||
| City: | MANKATO | ||||||||
| State: | MN | ||||||||
| PostalCode: | 560028674 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5076251811 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/10/2006 | ||||||||
| LastUpdateDate: | 07/10/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 07/10/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084N0400X | 43496 | MN | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Neurology |
ID Information
| ID | Type | State | Issuer | Description | 1328361 | 01 | MN | AMERICAS PPO | OTHER | 410849339 56001 C181 | 01 | CHAMPUS | OTHER | 0500173 | 01 | MN | MEDICA | OTHER | 151694 | 01 | MN | UCARE | OTHER | 071645600 | 05 | MN | MEDICAID | 0947127 | 01 | IA | MEDICAID | OTHER | 45D61DA | 01 | MN | BCBS | OTHER | 130024186 | 01 | RR MEDICARE | OTHER | HP32997 | 01 | MN | HEALTH PARTNERS | OTHER | NA2951027572 | 01 | MN | PREFERRED ONE | OTHER |