Provider Demographics
NPI:1023089232
Name:LYSTAD, LISA DOUGLASS (MD)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:DOUGLASS
Last Name:LYSTAD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:23250 CHAGRIN BLVD #5
Mailing Address - Street 2:BLDG #5 SUITE 440
Mailing Address - City:BEACHWOOD
Mailing Address - State:OH
Mailing Address - Zip Code:44122
Mailing Address - Country:US
Mailing Address - Phone:216-514-1864
Mailing Address - Fax:216-514-1867
Practice Address - Street 1:23250 CHAGRIN BLVD
Practice Address - Street 2:BLD 5 STE 440
Practice Address - City:BEACHWOOD
Practice Address - State:OH
Practice Address - Zip Code:44122
Practice Address - Country:US
Practice Address - Phone:216-514-1864
Practice Address - Fax:216-514-1867
Is Sole Proprietor?:No
Enumeration Date:2006-01-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
OH35061509L207W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207W00000XAllopathic & Osteopathic PhysiciansOphthalmology
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0884593Medicaid
F25182Medicare UPIN
LY0714482Medicare ID - Type Unspecified