Healthcare Provider Details

I. General information

NPI: 1023089232
Provider Name (Legal Business Name): LISA DOUGLASS LYSTAD MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23250 CHAGRIN BLVD BLD 5 STE 440
BEACHWOOD OH
44122
US

IV. Provider business mailing address

23250 CHAGRIN BLVD #5 BLDG #5 SUITE 440
BEACHWOOD OH
44122
US

V. Phone/Fax

Practice location:
  • Phone: 216-514-1864
  • Fax: 216-514-1867
Mailing address:
  • Phone: 216-514-1864
  • Fax: 216-514-1867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number35061509L
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: