Basic Information
| Provider Information | |||||||||
| NPI: | 1235576059 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HAMILTON | ||||||||
| FirstName: | LISA | ||||||||
| MiddleName: | MARIE SONGCO | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | D.O. | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | SONGCO | ||||||||
| OtherFirstName: | LISA MARIE | ||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | DO | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 823 GATEWAY CENTER WAY | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024541 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152300 | ||||||||
| FaxNumber: | 6192690083 | ||||||||
| Practice Location | |||||||||
| Address1: | 4725 MARKET ST | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921024715 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6195152560 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/03/2013 | ||||||||
| LastUpdateDate: | 03/17/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | 14772 | CA | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 14772 | 01 | CA | LIC | OTHER |