Healthcare Provider Details

I. General information

NPI: 1205242765
Provider Name (Legal Business Name): LISA DOAN BRESHEARS D.P.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA DOAN

II. Dates (important events)

Enumeration Date: 07/05/2014
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

299 W FOOTHILL BLVD STE 124
UPLAND CA
91786-3854
US

IV. Provider business mailing address

299 W FOOTHILL BLVD STE 124
UPLAND CA
91786-3854
US

V. Phone/Fax

Practice location:
  • Phone: 909-946-6643
  • Fax: 909-946-6130
Mailing address:
  • Phone: 909-946-6643
  • Fax: 909-946-6130

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE5372
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code213EP1101X
TaxonomyPrimary Podiatric Medicine Podiatrist
License NumberE5372
License Number StateCA
# 3
Primary TaxonomyY
Taxonomy Code213ES0103X
TaxonomyFoot & Ankle Surgery Podiatrist
License NumberE5372
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: