Provider Demographics
NPI:1235576059
Name:HAMILTON, LISA MARIE SONGCO (DO)
Entity type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE SONGCO
Last Name:HAMILTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:LISA MARIE
Other - Middle Name:
Other - Last Name:SONGCO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:823 GATEWAY CENTER WAY
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92102-4541
Mailing Address - Country:US
Mailing Address - Phone:619-515-2300
Mailing Address - Fax:619-269-0083
Practice Address - Street 1:4725 MARKET ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92102-4715
Practice Address - Country:US
Practice Address - Phone:619-515-2560
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-06-03
Last Update Date:2018-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14772207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA14772OtherLIC