Healthcare Provider Details

I. General information

NPI: 1326047432
Provider Name (Legal Business Name): LISMORE BURTON HERON MD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/20/2005
Last Update Date: 02/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1027 SE OCEAN BLVD
STUART FL
34996-2576
US

IV. Provider business mailing address

1027 SE OCEAN BLVD
STUART FL
34996-2576
US

V. Phone/Fax

Practice location:
  • Phone: 772-781-0222
  • Fax: 772-781-0008
Mailing address:
  • Phone: 772-781-0222
  • Fax: 772-781-0008

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RC0000X
TaxonomyCardiovascular Disease Physician
License NumberME0082280
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: