Provider Demographics
NPI:1801010657
Name:LISA EDGERTON
Entity type:Organization
Organization Name:LISA EDGERTON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:LISA
Authorized Official - Middle Name:
Authorized Official - Last Name:EDGERTON
Authorized Official - Suffix:
Authorized Official - Credentials:DR
Authorized Official - Phone:305-629-2669
Mailing Address - Street 1:114 NE 107TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7032
Mailing Address - Country:US
Mailing Address - Phone:305-629-2669
Mailing Address - Fax:305-981-2095
Practice Address - Street 1:114 NE 107TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33161-7032
Practice Address - Country:US
Practice Address - Phone:305-629-2669
Practice Address - Fax:305-981-2095
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-12
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Single Specialty