Healthcare Provider Details

I. General information

NPI: 1265881676
Provider Name (Legal Business Name): LISA MICHELLE TOM M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/07/2016
Last Update Date: 02/25/2025
Certification Date: 02/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5454 WISCONSIN AVE STE 950
CHEVY CHASE MD
20815-6912
US

IV. Provider business mailing address

2 PILLSBURY ST STE 100
CONCORD NH
03301-3549
US

V. Phone/Fax

Practice location:
  • Phone: 301-657-5700
  • Fax: 301-654-9132
Mailing address:
  • Phone: 603-224-2020
  • Fax: 603-228-7061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberD0095596
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberME145348
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License Number21488
License Number StateNH
# 4
Primary TaxonomyN
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License NumberMD210002800
License Number StateDC
# 5
Primary TaxonomyN
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberMD210002800
License Number StateDC
# 6
Primary TaxonomyY
Taxonomy Code207WX0009X
TaxonomyGlaucoma Specialist (Ophthalmology) Physician
License NumberD0095596
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: