Provider Demographics
NPI:1730332131
Name:RIVERA, LISA BAZEMORE (MD)
Entity type:Individual
Prefix:MS
First Name:LISA
Middle Name:BAZEMORE
Last Name:RIVERA
Suffix:
Gender:F
Credentials:MD
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Mailing Address - Street 1:3495 PIEDMONT RD NE
Mailing Address - Street 2:NINE PIEDMONT CENTER
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30305-1717
Mailing Address - Country:US
Mailing Address - Phone:404-364-7070
Mailing Address - Fax:
Practice Address - Street 1:3650 STEVE REYNOLDS BLVD
Practice Address - Street 2:KAISER PERMANENTE GWINNETT MEDICAL CENTER
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4506
Practice Address - Country:US
Practice Address - Phone:205-934-4794
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-29
Last Update Date:2022-01-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
390200000X
GA0685482084N0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084N0400XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyNeurology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program