Provider Demographics
NPI:1013039643
Name:DEROSIMO, LISA MARIE (MD MS)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:DEROSIMO
Suffix:
Gender:F
Credentials:MD MS
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:11535 SW 88TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33176-1002
Mailing Address - Country:US
Mailing Address - Phone:786-595-8000
Mailing Address - Fax:786-533-9576
Practice Address - Street 1:11535 SW 88TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33176-1002
Practice Address - Country:US
Practice Address - Phone:786-595-8000
Practice Address - Fax:786-533-9576
Is Sole Proprietor?:No
Enumeration Date:2007-04-04
Last Update Date:2015-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME 56721207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine