Provider Demographics
NPI:1104178193
Name:BRAND, LISA ELAINE (MD)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:ELAINE
Last Name:BRAND
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:ELAINE
Other - Last Name:SMALL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:5235 MISSION OAKS BLVD # 301
Mailing Address - Street 2:
Mailing Address - City:CAMARILLO
Mailing Address - State:CA
Mailing Address - Zip Code:93012-5400
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4542 LAS POSAS RD STE D
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93010-2521
Practice Address - Country:US
Practice Address - Phone:805-322-8490
Practice Address - Fax:805-586-8066
Is Sole Proprietor?:No
Enumeration Date:2012-10-15
Last Update Date:2023-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA126474208600000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery