MEDICARE: LISA BENEST MD

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	207N00000X	Dermatology Physician	G77204	CA

General Provider Information

NPI Number	:	1104898238
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LISA BENEST MD

Provider Business Mailing Address
First Line	:	1624 W OLIVE AVE
Second Line	:	SUITE B
City	:	BURBANK
State	:	CA
Zip	:	91506-2459
Country	:	US
Telephone Number	:	818-729-9149
Fax Number	:	818-729-9119

Provider Business Practice Location Address
First Line	:	1624 W OLIVE AVE
Second Line	:	SUITE B
City	:	BURBANK
State	:	CA
Zip	:	91506-2459
Country	:	US
Telephone Number	:	818-729-9149
Fax Number	:	818-729-9119

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/02/2006
Last Update Date	:	11/30/2009

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