Provider Demographics
NPI:1548512460
Name:LATHROUM, LISELLE (MD)
Entity type:Individual
Prefix:
First Name:LISELLE
Middle Name:
Last Name:LATHROUM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:230 CALLE VIENA
Mailing Address - Street 2:COLLEGE PARK
Mailing Address - City:SAN JUAN
Mailing Address - State:PR
Mailing Address - Zip Code:00921-4804
Mailing Address - Country:US
Mailing Address - Phone:787-413-0779
Mailing Address - Fax:
Practice Address - Street 1:230 CALLE VIENA
Practice Address - Street 2:COLLEGE PARK
Practice Address - City:SAN JUAN
Practice Address - State:PR
Practice Address - Zip Code:00921-4804
Practice Address - Country:US
Practice Address - Phone:787-413-0779
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-03
Last Update Date:2012-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PR030165-R282NC2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes282NC2000XHospitalsGeneral Acute Care HospitalChildren