Provider Demographics
NPI:1023015302
Name:GOLD, LISA CAMILLE (MD)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:CAMILLE
Last Name:GOLD
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 781076
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48278-1076
Mailing Address - Country:US
Mailing Address - Phone:317-528-4800
Mailing Address - Fax:317-865-1479
Practice Address - Street 1:1141 S INDIANA AVE
Practice Address - Street 2:
Practice Address - City:CROWN POINT
Practice Address - State:IN
Practice Address - Zip Code:46307-7205
Practice Address - Country:US
Practice Address - Phone:219-662-0700
Practice Address - Fax:219-662-0973
Is Sole Proprietor?:No
Enumeration Date:2005-07-01
Last Update Date:2023-07-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN01044839208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200084250Medicaid
ING24967Medicare UPIN
INM400049572Medicare PIN
IN202790AMedicare ID - Type Unspecified