Healthcare Provider Details

I. General information

NPI: 1629051651
Provider Name (Legal Business Name): LISA S GAMELL MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/23/2005
Last Update Date: 10/15/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3242 COVE BEND DR
TAMPA FL
33613-2752
US

IV. Provider business mailing address

3242 COVE BEND DR
TAMPA FL
33613-2752
US

V. Phone/Fax

Practice location:
  • Phone: 813-265-6940
  • Fax: 813-908-3937
Mailing address:
  • Phone: 813-265-6940
  • Fax: 813-908-3937

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberME99976
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME 99976
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: