Healthcare Provider Details

I. General information

NPI: 1477762599
Provider Name (Legal Business Name): LISA RICHARDSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/22/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

849 W 34TH ST
LOS ANGELES CA
90089-0079
US

IV. Provider business mailing address

4770 DON MIGUEL DR APT 16
LOS ANGELES CA
90008-4146
US

V. Phone/Fax

Practice location:
  • Phone: 213-740-9355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080A0000X
TaxonomyPediatric Adolescent Medicine Physician
License NumberA063387
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: