Healthcare Provider Details

I. General information

NPI: 1376543660
Provider Name (Legal Business Name): LISA D CHESTNUT M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2005
Last Update Date: 10/04/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4687 POUNCEY TRACT ROAD KIDMED
GLEN ALLEN VA
23059-5802
US

IV. Provider business mailing address

509 WESTON CT
RICHMOND VA
23238-5583
US

V. Phone/Fax

Practice location:
  • Phone: 804-422-5437
  • Fax: 804-422-5438
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number0101050845
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: