Healthcare Provider Details

I. General information

NPI: 1639350820
Provider Name (Legal Business Name): LISA R. GRYSEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/16/2007
Last Update Date: 07/13/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11661 PRESTON RD SUITE 120
DALLAS TX
75230-2745
US

IV. Provider business mailing address

3237 LANCELOT DR
DALLAS TX
75229-5017
US

V. Phone/Fax

Practice location:
  • Phone: 214-363-7242
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberM9239
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: