Basic Information
| Provider Information | |||||||||
| NPI: | 1427029248 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ESTERLE | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | ESTERLE GRANT | ||||||||
| OtherFirstName: | LISA | ||||||||
| OtherMiddleName: | MARIE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 807 E WASHINGTON ST | ||||||||
| Address2: | STUIE 150 | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307254777 | ||||||||
| FaxNumber: | 3307256334 | ||||||||
| Practice Location | |||||||||
| Address1: | 807 E WASHINGTON ST | ||||||||
| Address2: | STUIE 150 | ||||||||
| City: | MEDINA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 442563338 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3307254777 | ||||||||
| FaxNumber: | 3307256334 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2006 | ||||||||
| LastUpdateDate: | 12/23/2019 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 12/23/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 34006465 | OH | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 2127273 | 05 | OH | MEDICAID |