Healthcare Provider Details

I. General information

NPI: 1932109964
Provider Name (Legal Business Name): LISA ERELIS RADIX MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/01/2005
Last Update Date: 09/26/2023
Certification Date: 09/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3801 N HIGHWAY 19A STE 400
MOUNT DORA FL
32757-2228
US

IV. Provider business mailing address

3801 N HIGHWAY 19A STE 400
MOUNT DORA FL
32757-2228
US

V. Phone/Fax

Practice location:
  • Phone: 352-383-1245
  • Fax: 270-887-8340
Mailing address:
  • Phone: 352-383-1245
  • Fax: 270-887-8340

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number3663
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License Number32227
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207RN0300X
TaxonomyNephrology Physician
License NumberME104289
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: