Healthcare Provider Details

I. General information

NPI: 1053597674
Provider Name (Legal Business Name): LISA SUZANNE USDAN M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2008
Last Update Date: 07/18/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6401 POPLAR AVE, SUITE 420
MEMPHIS TN
38120
US

IV. Provider business mailing address

6401 POPLAR AVE, SUITE 420
MEMPHIS TN
38119
US

V. Phone/Fax

Practice location:
  • Phone: 901-843-1045
  • Fax: 901-843-1206
Mailing address:
  • Phone: 901-843-1045
  • Fax: 901-843-1206

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number234654
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number43169
License Number StateTN
# 3
Primary TaxonomyY
Taxonomy Code207RE0101X
TaxonomyEndocrinology, Diabetes & Metabolism Physician
License Number0000043169
License Number StateTN
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number43169
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: