Healthcare Provider Details

I. General information

NPI: 1407048697
Provider Name (Legal Business Name): LISA LAFOREST M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/13/2007
Last Update Date: 04/26/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

IV. Provider business mailing address

2525 CHICAGO AVE
MINNEAPOLIS MN
55404-4518
US

V. Phone/Fax

Practice location:
  • Phone: 612-813-6248
  • Fax:
Mailing address:
  • Phone: 612-813-6248
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number099578
License Number StateOH
# 2
Primary TaxonomyY
Taxonomy Code2085P0229X
TaxonomyPediatric Radiology Physician
License Number50424
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: