Basic Information
| Provider Information | |||||||||
| NPI: | 1700993805 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SULLIVAN VEDDER | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | A | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3301 W FOREST HOME AVE | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532152843 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142197956 | ||||||||
| FaxNumber: | 4142197150 | ||||||||
| Practice Location | |||||||||
| Address1: | 945 N 12TH ST | ||||||||
| Address2: | |||||||||
| City: | MILWAUKEE | ||||||||
| State: | WI | ||||||||
| PostalCode: | 532331305 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4142197956 | ||||||||
| FaxNumber: | 4142197150 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/24/2006 | ||||||||
| LastUpdateDate: | 11/24/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 11/24/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 44418 | WI | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | BS8085880 | 01 | DEA NUMBER | OTHER | 34330700 | 05 | WI | MEDICAID |