Provider Demographics
NPI:1053395327
Name:HART, LISA E (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:E
Last Name:HART
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:E
Other - Last Name:MAST
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:715 W MAIN ST STE S
Mailing Address - Street 2:
Mailing Address - City:JENKS
Mailing Address - State:OK
Mailing Address - Zip Code:74037-3553
Mailing Address - Country:US
Mailing Address - Phone:918-745-0501
Mailing Address - Fax:918-747-9778
Practice Address - Street 1:715 W MAIN ST STE S
Practice Address - Street 2:
Practice Address - City:JENKS
Practice Address - State:OK
Practice Address - Zip Code:74037-3553
Practice Address - Country:US
Practice Address - Phone:918-745-0501
Practice Address - Fax:918-747-9778
Is Sole Proprietor?:No
Enumeration Date:2005-12-01
Last Update Date:2020-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK4161208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK200182250BMedicaid