Healthcare Provider Details

I. General information

NPI: 1801825914
Provider Name (Legal Business Name): LISA DURHAM HOUCHIN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/01/2006
Last Update Date: 07/15/2024
Certification Date: 04/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4501 CAMERON VALLEY PKWY STE 200
CHARLOTTE NC
28211-4297
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-512-3636
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number9901206
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number9901206
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number9901206
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: