MEDICARE: LISA N GERVIN M.D.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207R00000X	Internal Medicine Physician	ME165140	FL

General Provider Information

NPI Number	:	1962425157
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA N GERVIN M.D.

Provider Business Mailing Address
First Line	:	368 E DANIA BEACH BLVD
Second Line	:
City	:	DANIA
State	:	FL
Zip	:	33004-3020
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	368 E DANIA BEACH BLVD
Second Line	:
City	:	DANIA
State	:	FL
Zip	:	33004-3020
Country	:	US
Telephone Number	:	305-685-5688
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	06/26/2024

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