Healthcare Provider Details

I. General information

NPI: 1538118435
Provider Name (Legal Business Name): LISA MOED GRUSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7901 4TH AVE
BROOKLYN NY
11209-3957
US

IV. Provider business mailing address

330 E 70TH ST APT 5D
NEW YORK NY
10021-8634
US

V. Phone/Fax

Practice location:
  • Phone: 718-791-5800
  • Fax:
Mailing address:
  • Phone: 917-647-8112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number229198
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: