Healthcare Provider Details

I. General information

NPI: 1578566907
Provider Name (Legal Business Name): MILLSBORO FAMILY PRACTICE, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 LAUREL RD
MILLSBORO DE
19966-1732
US

IV. Provider business mailing address

201 LAUREL RD
MILLSBORO DE
19966-1732
US

V. Phone/Fax

Practice location:
  • Phone: 302-934-7344
  • Fax: 302-934-7345
Mailing address:
  • Phone: 302-934-7344
  • Fax: 302-934-7345

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberC20005747
License Number StateDE

VIII. Authorized Official

Name: DR. LISA ANN MARTIN
Title or Position: PHYSICIAN/OWNER
Credential: D.O.
Phone: 302-934-7344