Healthcare Provider Details

I. General information

NPI: 1952301426
Provider Name (Legal Business Name): LISA MARIE DETOURNAY DPM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/27/2005
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1611 NW 12TH AVE
MIAMI FL
33136-1005
US

IV. Provider business mailing address

1235 MARIPOSA AVE APT 2
CORAL GABLES FL
33146-3252
US

V. Phone/Fax

Practice location:
  • Phone: 305-710-1971
  • Fax:
Mailing address:
  • Phone: 305-710-1971
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberPO1933
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: