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General NPI Number Information
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NPI Number | 1124197173
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Entity Type | Individual
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Provider Name | LISA DANIELLE BROSTROM MD, FACS
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Gender | Female
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Dates
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Enumeration Date | 11/06/2006
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Last Update Date | 09/12/2019
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Provider Practice Location Address
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Address Line | 3551 ROGER BROOKE DR BLDG 3600
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234-4504
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Country | US
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Telephone | 210-269-6113
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Fax |
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Provider Business Mailing Address
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Address Line | 3551 ROGER BROOKE DR BLDG 3600
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City | FORT SAM HOUSTON
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State | TX
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Zip | 78234-4504
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Country | US
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Telephone | 210-269-6113
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208200000X
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Taxonomy Name | Plastic Surgery Physician
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License Number | L4266
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License Number State | TX
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