Healthcare Provider Details

I. General information

NPI: 1598083974
Provider Name (Legal Business Name): LISA JOY UNDERLAND DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/11/2010
Last Update Date: 06/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 EAST 210TH ST
BRONX NY
10467
US

IV. Provider business mailing address

3411 WAYNE AVE
BRONX NY
10467-2509
US

V. Phone/Fax

Practice location:
  • Phone: 800-636-6683
  • Fax:
Mailing address:
  • Phone: 832-867-4580
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberBP10037148
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License NumberP6292
License Number StateTX
# 3
Primary TaxonomyY
Taxonomy Code2080P0205X
TaxonomyPediatric Endocrinology Physician
License Number60 283152
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: