Healthcare Provider Details

I. General information

NPI: 1588982003
Provider Name (Legal Business Name): LISA MIDORI DODOBARA-GRIFFITH D. O.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/07/2010
Last Update Date: 04/27/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

35TH MEDICAL GROUP, MISAWA AIR BASE, JAPAN
APO AP
96319-0037
US

IV. Provider business mailing address

PSC 76 BLDG 99
APO AP
96319-0037
US

V. Phone/Fax

Practice location:
  • Phone: 315-226-6200
  • Fax:
Mailing address:
  • Phone: 315-226-6200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOP60241084
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: