Provider Demographics
NPI:1093816266
Name:EDGERTON, LISA MARIE (DO)
Entity Type:Individual
Prefix:DR
First Name:LISA
Middle Name:MARIE
Last Name:EDGERTON
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:114 NE 107TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI SHORES
Mailing Address - State:FL
Mailing Address - Zip Code:33161-7032
Mailing Address - Country:US
Mailing Address - Phone:786-390-8684
Mailing Address - Fax:305-654-5270
Practice Address - Street 1:114 NE 107TH ST
Practice Address - Street 2:
Practice Address - City:MIAMI SHORES
Practice Address - State:FL
Practice Address - Zip Code:33161-7032
Practice Address - Country:US
Practice Address - Phone:786-390-8684
Practice Address - Fax:305-654-5270
Is Sole Proprietor?:Yes
Enumeration Date:2006-09-26
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLOS 8636207QA0505X
MI5101013599207R00000X, 208M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No207QA0505XAllopathic & Osteopathic PhysiciansFamily MedicineAdult Medicine
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL2647761 00Medicaid
FL62879AMedicare ID - Type UnspecifiedPROVIDER NUMBER
FLH32748Medicare UPIN