Basic Information
| Provider Information | |||||||||
| NPI: | 1659489532 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LAXSON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | K | ||||||||
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| Credential: | M.D. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 221 S 6TH ST | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478074214 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320564 | ||||||||
| FaxNumber: | 8122423842 | ||||||||
| Practice Location | |||||||||
| Address1: | 5500 S US HIGHWAY 41 | ||||||||
| Address2: | |||||||||
| City: | TERRE HAUTE | ||||||||
| State: | IN | ||||||||
| PostalCode: | 478024745 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8122320564 | ||||||||
| FaxNumber: | 8122423842 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/29/2006 | ||||||||
| LastUpdateDate: | 09/26/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 01061236A | IN | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | P00315179 | 01 | RAILROAD MCARE PALAMETTO | OTHER | 351904269221 | 01 | CARESOURCE MEDICAID | OTHER | 7014223 | 01 | CIGNA | OTHER | 740329 | 01 | HEALTHLINK | OTHER | 000000384966A | 01 | ANTHEM | OTHER | 7411388 | 01 | AETNA | OTHER |